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High Performance CPR
San Luis Obispo County EMS Agency
Emergency Medical Services Fund
Thank you to our sponsors!!!
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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%
What is Happening in SLO?
(24 month review)
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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%
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
• History
• Science
• Elements of HPCPR
• CPR Rate/Depth/Recoil
• Minimal Interruptions
• Airway management
• Translating knowledge into practice
• Hands-on practice
• Simulation
• Review
Objectives for today
HISTORY
CPR is over 50 years old, but recent changes have
shown increases in survival
A
B
A. Peter Safar, 1950s
B. Early symposium on CPR
1961
Figure 2: Temporal Trends in OHCA Survival Over Time
(Sasson et. al. Circuation: Cardiovascular Quality and Outcomes Nov. 2009.)
History has provide a better understanding of CPR
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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
1960 >2010
What have we learned about CPR?
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
The Result > HPCR or PIT Crew Model
GOAL:
MINIMIZE INTERRUPTIONS
Common “Tasks” > Interruptions
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Airway interventions and IVs
Ventilations
Pulse checks
Rhythm analysis
Defibrillation
Changing compressors
Patient movement
• 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
Interruptions - Old vs New
Single rescuer performing 30:2 with realistic 16 sec.
interruption of chest compressions for MTM ventilations
160
Cerebral Perfusion
Pressures
No Cerebral
Perfusion
5 sec
mmHg
120
80
40
Coronary Perfusion Pressures
0
Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525
Time (sec)
160
Perfusion with
continuous
compressions
Single
rescuer performing
continuous chest compressions
5 sec
mmHg
120
Continuous Cerebral Perfusion Pressures
80
40
Coronary Perfusion Pressures
0
Time (sec)
Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525
Shock success, percent
Defibrillation success and 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
HPCPR Goal:
Less than 5-10 second break
in every
2 minute cycle of CPR
GOAL:
QUALITY CPR
RATE/DEPTH/RECOIL
Rate Matters
Chest compression rates of auto pulse devices
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
DEPTH
Survival better with compressions >2 inches deep
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
Shock success, percent
Shock success by compression depth
p=0.02
n=10
n=13
n=14
n=5
Compression depth, inches
Edelson et al, 2006
RECOIL OR
COMPRESSION FRACTION
How Does CPR Cause Blood Flow?
Thoracic Pump
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Ensure Total Chest Recoil with:
1) Lifting palm during compressions
or
2) Using feedback device
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VENTILATIONS:
SMALL AMOUNT ON UP STROKE
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)
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Trauma
Drowning
Hypoxic Cardiac Arrest
Suspected Respiratory Cause
Overdose, etc.
Hyperventilation during CPR = Decrease in Survival
86%
100%
p= 0.006
80%
% survival 60%
13%
40%
20%
0%
12
30
# ventilations per minute
Aufderheide et al. Circulation 2004; 109:1960-5
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.
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.
Bringing Science to
Practice
High-Functioning EMS CPR Teams
Starts with the Bystanders
Survival to Hospital Discharge
Survival after Bystander CPR for OHCA in Arizona (2005 to 2010)
Compression Only CPR (COCPR) Advocated and Taught
35%
A. All OHCA
B. Witnessed/Shockable
30%
AOR 1.6 (95% CI, 1.08-2.35)
P < 0.001
25%
20%
33.7%
15%
10%
5%
0%
7.8%
Std-CPR
13.3%
COCPR
17.7%
Std-CPR
Bobrow, et al. JAMA 2010:304:1447-1454
COCPR
Dispatcher-assisted hands-only CPR
2010
Bystander contacted 9-1-1
standard CPR (n=960)
11.5%
chest compression alone (n=981)
Survival to DC
14.4%
EMS Can Further Improving
Cardiac Arrest Outcomes?
HP CPR (Pit) Crew
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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.
Key Elements to HPCPR
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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
CPR Dashboard Display
ETCO2
CPR Quality
Release
Perfusion
performance
indicator
Depth indicator
Rate indicator
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
Key to success:
Adapt the concepts to your
program
Position 1 (P1) -Initial Team Leader
POI
AED
• 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)
P1
P2
2 Person BLS
• 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
Position 1 (P1) –
P3
AED/
Monitor
• 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 10th compression and
keeps count of compressions
Position 2 (P2)
P1
P2
3 Person
• Activates Metronome
• Assists with application AED/ALS Monitor with minimal
interruption of compressions
• Provides respirations on upstroke of 10th compression and
keeps count of compressions
• Alternates with P1 at 200 compression
• When not doing compressions and keeps count of
compressions
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
P3
AED/
Monitor
P1
Position 2 (P2)
• Activates Metronome
• Applies and operates AED /Monitor
• Ventilates 200-400cc every 10 compression
• Alternates with P1 at 200 compression /keeping count
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
P2
P4
4 Person BLS/ALS
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
Stay on scene and work the code until:
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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 nonviable patient
Exceptions: children and other causes of cardiac arrest i.e. trauma,
drowning, OD, etc.
How long …
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
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)
Cardiac arrest performance data
Performance Review: each team member will receive a summary of each
code highlighting successes and potential areas for improvement
Successful Programs:
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Measure Outcomes
Provide Feedback
Continuous Improvement Program
Practice regularly
• Cardiac Arrests Outcomes Can Improve!
• BLS CPR quality makes the biggest impact
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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
Take Home Points
DEATH TELLING
• Assign someone to be
the primary
communicator with
the family
• Be honest and direct
• Ask about
support/resources
Death telling
Time to practice….