Aiming for high quality CPR: why it matters and how we can get there

Benjamin S. Abella, MD, MPhil, FACEP Clinical Research Director

Center for Resuscitation Science Department of Emergency Medicine University of Pennsylvania

Laerdal SUN workshop Philadelphia, December 2014

Speaker disclosures

Research Funding: NIH - NHLBI

American Heart Association

Medtronic Foundation

Speaking Honoraria: Philips Healthcare

Advisory Board: HeartSine Technologies

CardioReady

Volunteer: American Heart Association

Sudden Cardiac Arrest Association

Electrical recording of the heart rhythm:

Normal rhythm: heart is moving blood (functional “cardiac output”)

Cardiac arrest rhythm: chaotic rhythm means no blood flow (no functional cardiac output)

In cardiac arrest, abrupt and total loss of cardiac output Uniformly fatal unless immediate treatment given (e.g. CPR)

Cardiac arrest

400,000 arrests / year

2 / 3 Out-of-hospital

1 / 3 In-hospital

survival to hospital

discharge 1-5% 10-20%

Seattle: 10-20%!

Cardiac arrest epidemiology in the US

Time

% S

urvi

ving

arrest

CPR defibrillation

ROSC

hospital discharge

Mortality from cardiac arrest

Drs. Knickerbocker, Kouwenhoven, and Jude – Johns Hopkins, 1950s – studied defibrillation and chest compressions in the laboratory

Development of chest compressions

1961

Approaching 50 years of modern CPR

A. Peter Safar, 1950s

B. Early symposium on CPR

A B

“Chain of Survival”

Prompt Access

Early CPR

ACLS Care

Early Defib

ACLS Provider Manual (American Heart Association)

Cardiac arrest: fundamentals of therapy

Chest compression alone CPR

Recent publication from the American Heart Association, endorsing the use of dispatch 911 CPR instructions:

Is patient conscious?

Is patient breathing normally?

START CPR; INSTRUCTIONS

Sample algorithm for dispatch recognition of cardiac arrest

“no”

“no”

Lerner et al, Circulation 2012

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

Hallstrom et al, 2000

Bystander contacted 9-1-1

standard CPR (n=279) chest compression alone (n=241)

29/279 (10.4%) 35/241 (14.6%)

Improvement due to: ? less time to train ? better CPR strategy

Chest compression alone CPR

p=0.18

Bystander contacted 9-1-1

standard CPR (n=960) chest compression alone (n=981)

Chest compression alone CPR: revisited

2010

Survival to DC

11.5% 14.4% (OR 2.9)

1996

Ventilation was the biggest technical challenge for lay rescuers Mouth-to-mouth is HARD

Unrealistic to ventilate well?

2012

Lay public feels more Confident with CC only More willing to share Information with others

Compression-only: training is easier

Berg et al, 2001

Blo

od

pre

ssur

e

Time

= chest compression

Standard CPR vs CC alone

Berg et al, 2001

Blo

od

pre

ssur

e

Time

= chest compression

Standard CPR vs CC alone

“No flow” / compression fraction

0-20 21-40 41-60 61-80 81-100 comp fraction, %

Surv

iva

l to

dis

cha

rge

, %

0

10

2

0

3

0

Christenson J et al, Circ 2009 poor survival with lowest compression fraction in OHCA

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%

Chest compression depth

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

Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation

Defib first - AHA CPR (90 sec) first, then defib 42 months 36 months

24% (155/639) 30% (142/478) p=0.04

Cobb et al, 1999

CPR first may improve survival

0 2 4 6 8 10 12 14

0.5

0.4

0.3

0.2

0.1

0

Wik et al, 2003

CPR first Standard care

pro

ba

bili

ty o

f sur

viva

l

time from collapse, min

CPR first may improve survival: RCT

p=0.006

CPR sensing and recording defibrillator

Similar defibrillators now made by both Philips and Zoll

ventilations

ECG

compressions

rhythm check ECG: v fib

shock given

Arrest transcript

ECG: v tach

Actual arrest transcript: U of C, 2004

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)

Num

be

r of 3

0 se

c s

eg

me

nts

300

250

200

150

100

50

0

n=1626 segments

Chest compression rates

Abella et al, 2005

No ROSC ROSC

10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 >120

Chest compression rate (min-1)

Mean rate, ROSC group 90 ± 17 *

Mean rate, no ROSC group 79 ± 18 *

210 180 150 120 90 60 30 0

Num

be

r of 3

0 se

c s

eg

me

nts

Chest compression rates by survival

Abella et al, 2005

p=0.003

CPR renaissance: measuring CPR

Valenzuela et al, Circ 2005 Wik et al, JAMA 2005 Abella et al, JAMA 2005 Aufderheide et al,Circ 2004

Aufderheide et al, 2004

mean ventilation rate: 30 ± 3.2

first group: 37 ± 4 after retraining: 22 ± 3

16 seconds

v v v v v v v v v v

Hyperventilation during EMS resuscitation

Pause before shock

4:55 5:00 5:05 5:10

Com

pres

sion

s

ECG

Chest compression pauses before shocks

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

VF re

mov

ed, p

erce

nt

90%

10%

55% 64%

p=0.003

Dose-effect of pre-shock pauses

Edelson et al, 2006

Possible model underlying these data

1. Slow compression rates 2.  Frequent and lengthy pauses 3. Shallow compressions 4. Hyperventilation

Current CPR quality: summary

The problem with cardiac arrest

The military solution

l  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

Debriefing intervention

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

AHA statement on CPR quality

2013

Concept of “report cards” for resuscitation

CPR in the workplace

Friday, June 13, 2008 Tim Russert, TV correspondent Known asymptomatic coronary dz Suffered AMI à 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?

March 17, 2012 Fabrice Muamba had cardiac arrest while on UK football field Arrest duration was over 78 minutes

Prolonged CPR and shocks – Full neurologic recovery

Demonstration of CPR saving lives

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% à 9.1%)

New directions in CPR: Hands-only CPR – evidence suggests mouth-to-mouth may not be required, especially for bystander response New for 2010 guidelines: Airway-Breathing-Circulation is now Circulation-Airway-Breathing

C A B

Guidelines update 2010

The key importance of CPR

2009

Reflected in the poor impact of ACLS meds:

Randomized trial of epinephrine versus no epinephrine For EMS treated cardiac arrest à NO SURVIVAL BENEFIT!

Assessment during CPR is poor

In 2010, few options available to obtain “output” from patients during resuscitation

Patient receiving care

Treatment (input)

Effects (output)

In 2010, few options available to obtain “output” from patients during resuscitation

Patient receiving care

Treatment (input)

Effects (output)

Patient with pneumonia antibiotics

Temp curve wbc count

Assessment during CPR is poor

Progress in resuscitation inputs/outputs

Time (years)

Qu

alit

y

CPR introduced

30:2 CPR

CPR quality emphasis

Pulse check

Rhythm strip

Pulse check

Rhythm strip

Pulse check

Rhythm strip

Problem with CPR quality recording

CPR recording gives “incorrect” output: measures provider, not patient

Patient with pneumonia antibiotics

Temp curve wbc count

medication log sheet

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 carbon dioxide (ET-CO2)

expiration inspiration

ET-CO2

CO2

Advantages: non-invasive clinically available extensively studied

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 Kelsey Sheak Marisa Cinousis Emily Esposito Raghu Seethela