CPR quality and saving lives from cardiac arrest Benjamin S. Abella, MD, MPhil, FACEP Clinical Research Director Center for Resuscitation Science Department of Emergency Medicine University of Pennsylvania RACI – May 2014 Speaker disclosures Research Funding: NIH – NHLBI R18 Philips Healthcare Doris Duke Foundation Medtronic Foundation Speaking Honoraria: Medivance Corporation Advisory Board: HeartSine Technologies Velomedix Corporation Volunteer: American Heart Assoc. Sudden Cardiac Arrest Assoc. Cardiac arrest Electrical recording of the heart rhythm: Cardiac Normal arrest rhythm: rhythm: chaotic heart rhythm is moving means no blood blood flow (no(functional functional “cardiac cardiac output) output”) In cardiac arrest, abrupt and total loss of cardiac output Uniformly fatal unless immediate treatment given (e.g. CPR) Cardiac arrest epidemiology in the US 400,000 arrests / year 2/3 Out-of-hospital 1-5% survival to hospital discharge 1/3 In-hospital 10-20% Seattle: 10-20%! Mortality from cardiac arrest % Surviving arrest CPR defibrillation ROSC hospital discharge Time Development of chest compressions Drs. Knickerbocker, Kouwenhoven, and Jude – Johns Hopkins, 1950s – studied defibrillation and chest compressions in the laboratory Approaching 50 years of modern CPR A B A. Peter Safar, 1950s B. Early symposium on CPR 1961 Cardiac arrest: fundamentals of therapy “Chain of Survival” Prompt Access Provider Manual Early ACLS Early ACLS (American Association) CPR DefibHeart Care Chest compression alone CPR Dispatch-assisted CPR and AED use If someone calls 911 and doesn’t know CPR or how to use an AED, the dispatcher can coach them on the spot Growing concept across the US Recent publication from the American Heart Association, endorsing the use of dispatch 911 CPR instructions: Is patient conscious? “no” Is patient breathing normally? Sample algorithm for dispatch recognition of cardiac arrest “no” START CPR; INSTRUCTIONS Lerner et al, Circulation 2012 Chest compression alone CPR Bystander contacted 9-1-1 standard CPR (n=279) 29/279 (10.4%) chest compression alone (n=241) 35/241 (14.6%) Improvement due to: ? less time to train ? better CPR strategy p=0.18 Hallstrom et al, 2000 Chest compression alone CPR: revisited 2010 Bystander contacted 9-1-1 standard CPR (n=960) chest compression alone (n=981) 11.5% 14.4% Survival to DC (OR 2.9) Blood pressure Standard CPR vs CC alone Time = chest compression Berg et al, 2001 Blood pressure Standard CPR vs CC alone Time = chest compression Berg et al, 2001 Survival to discharge, % 0 10 20 30 “No flow” / compression fraction Christenson J et al, Circ 2009 poor survival with lowest compression fraction in OHCA 0-20 21-40 41-60 61-80 81-100 comp fraction, % Chest compression depth CPP, mm Hg 40 2 inches vs 1.5 inches 32 Survival: 100% 24 16 15% 8 0 1 2 3 CPR duration, min ICCM, 2005 Chest compression depth CCM 2012 CPR quality and survival 2013 Rate of 90-100 may be best; too slow or too fast may yield worse outcomes CPR quality and survival 2013 Deeper compressions Favors survival; no max Depth identified CPR first may improve survival Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation 24% (155/639) 30% (142/478) p=0.04 Defib first - AHA CPR (90 sec) first, then defib 42 months 36 months Cobb et al, 1999 CPR first may improve survival: RCT probability of survival 0.5 CPR first Standard care 0.4 0.3 0.2 0.1 p=0.006 0 0 2 4 6 8 10 12 time from collapse, min 14 Wik et al, 2003 CPR sensing and recording defibrillator Similar defibrillators now made by both Philips and Zoll Actual arrest transcript: U of C, 2004 Arrest transcript ventilations rhythm check ECG compressions ECG: v tach ECG: v fib shock given Chest compression rates Number of 30 sec segments 300 n=1626 segments 250 200 150 100 50 0 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) Abella et al, 2005 Chest compression rates by survival Mean rate, ROSC group 90 ± 17 * Number of 30 sec segments 210 p=0.003 180 Mean rate, no ROSC group 79 ± 18 * 150 No ROSC ROSC 120 90 60 30 0 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 Chest compression rate (min-1) Abella et al, 2005 >120 CPR renaissance: measuring CPR Valenzuela et al, Circ 2005 Wik et al, JAMA 2005 Abella et al, JAMA 2005 Aufderheide et al,Circ 2004 Hyperventilation during EMS resuscitation 16 seconds v v v v v v v v v v mean ventilation rate: 30 ± 3.2 first group: 37 ± 4 after retraining: 22 ± 3 Aufderheide et al, 2004 Chest compression pauses before shocks 5:00 5:05 Compressions ECG 4:55 Pause before shock 5:10 VF removed, percent Dose-effect of pre-shock pauses 100 80 90% 60 p=0.003 64% 55% 40 20 10% 0 ≤10.3 (n=10) 10.5-13.9 (n=11) 14.4-30.4 (n=11) ≥33.2 (n=10) Pre-shock pause, seconds Edelson et al, 2006 Possible model underlying these data Current CPR quality: summary 1. Slow compression rates 2. Frequent and lengthy pauses 3. Shallow compressions 4. Hyperventilation The problem with cardiac arrest The military solution Debriefing intervention ! Code review investigation: – All residents and students rotating through resuscitation team roles – Debrief teams on their events – Weekly 30-45 min resuscitation debriefing/ teaching sessions Impact of CPR feedback and debriefing Edelson et al, 2008 Impact of CPR feedback and debriefing Edelson et al, 2008 Impact of CPR feedback and debriefing EMS version of the Edelson 2008 study Performed using Zoll feedback defibrillators in Arizona Impact of CPR feedback and debriefing CPR in the workplace Friday, June 13, 2008 Tim Russert, TV correspondent Known asymptomatic coronary dz Suffered AMI " cardiac arrest Attempted resuscitation (CPR and defibrillation) failed Unknown CPR quality or pre-shock pause time CPR in the home Friday, June 25, 2009 Michael Jackson died at home Respiratory arrest from drug OD Attempted resuscitation (CPR and defibrillation) failed CPR performed in the bed – questionable quality, pauses in performance? Demonstration of CPR saving lives March 17, 2012 Fabrice Muamba had cardiac arrest while on UK football field Was successfully revived after prolonged CPR / resuscitation efforts Arrest duration was over 78 minutes Received CPR and multiple shocks Improving EMS care with “CC only” Bobrow et al, 2008 Interventions: 1. Significantly delay intubation 2. 200 compressions before first shock 3. Minimize pre and post shock pauses Tripled survival to hospital discharge (3.8% " 9.1%) Guidelines update 2010 New directions in CPR: Hands-only CPR – evidence suggests mouth-to-mouth may not be required, especially for bystander response New for 2010 guidelines: A B C Airway-Breathing-Circulation is now Circulation-Airway-Breathing The key importance of CPR Reflected in the poor impact of ACLS meds: 2009 Randomized trial of epinephrine versus no epinephrine For EMS treated cardiac arrest " NO SURVIVAL BENEFIT! Assessment during CPR is poor In 2010, few options available to obtain “output” from patients during resuscitation Treatment (input) Effects (output) Patient receiving care Assessment during CPR is poor In 2010, few options available to obtain “output” from patients during resuscitation Treatment (input) Effects (output) Patient receiving care antibiotics Patient with pneumonia Temp curve wbc count Progress in resuscitation inputs/outputs AEDs Quality CPR Defibrillation Pulse check Pulse check Pulse check Rhythm strip Rhythm strip Rhythm strip Time (years) Problem with CPR quality recording CPR recording gives “incorrect” output: measures provider, not patient medication log sheet antibiotics Patient with pneumonia Temp curve wbc count Candidate patient-based outputs Need methods to measure physiology Physiologic measurement Example Coronary perfusion pressure Paradis NA, 1990 Arterial pressure Rivers EP, 1993 Cerebral oximetry Newman DH, 2004 Blood markers Adrie C, 2002 End-tidal CO2 Ornato, 1989 End-tidal CO2 Advantages: non-invasive clinically available extensively studied ET-CO2 CO2 expiration inspiration Does ET-CO2 correlate with CPR quality? Sheak et al, AHA abstract presentation 2013 Key “take home” points 1. Cardiac arrest is not hopeless! 2. CPR quality has big impact 3. Minimize ventilations 4. Maximize chest compression rate and depth 5. Consider CPR feedback tools and code debriefing Acknowledgements Lance Becker Marion Leary Bob Neumar Dave Gaieski Roger Band Brendan Carr Barry Fuchs Dan Kolansky Vinay Nadkarni Raina Merchant Daniel Herzberg David Fried Emily Esposito Raghu Seethela CRS Center for Resuscitation Science
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