Download The state of CPR

THE STATE OF
RESUCITATION
2015
THE CPR WE KNOW AND LOVE
 Chain of Survival
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Immediate Recognition
Early CPR
Rapid Defib
Effective ALS
Intergrated Post Care
 CAB not ABC
 No breathing or only gasping
 Pulse checks limit to ten seconds
COMPRESSION
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Push hard push fast
Lower half of the sternum
Allow for full chest recoil
*Rate at least 100 per minute*
Depth 1/3 for Ped to at least 2 inches for adults
Limit interruptions
Compression
 One rescuer
 Adult-30:2
 Ped (Infant and Child)-30:2
 Two Rescuer
 Adult-30:2
 Ped (Infant and Child) 15:2
VENTILATIONS
 Low pressure
 Patients with obstructed airways or poor lung compliance may
require more
 Chest rise
 Rate
 Adult 1 breath every 5-6 seconds
 Pediatric 1 breath every 3-5 seconds
 Asynchronous with Advanced Airway
CHANGES & WHY THEY ARE
IMPORTANT?
 Collective learning
 Increase learning rate
 Business “SAVING LIVES”
WHAT ARE THE CHANGES?
 Compressions
 Pit crew
 CCR
 Ventilations
 O2
 ???????????
COMPRESSIONS
Rate and
depth
Metronome
Mechanical
devices
RATE AND DEPTH
 Chest Compression fraction
 Time of the chest
 Goal 80%
 Rates 100-120 per minute.
 Depth still 2 inches and 1/3 in children
 Full chest recoil avoid excessive ventilations
METRONOME AND COMPRESSION
MEASUREMENT
 Metronome-Life Pack 15
 Physio-control TFI and Zoll
MECHANICAL DEVICES
 Piston
 Active Compression-Decompression ACD devices
 Load distributing bands
 Perceived benefits
 Final Conclusion-MFD and RAA
PIT CREW CPR
 Pit Crew CPR
 Each responder has one function
 Engineered to be the same
 Priorities are the same each time
 Compression-CF
 Defibrillation-Shock/Don’t shock, pre-charge
 Controlled ventilations
 Stay and Play not Load and Go
PIT CREW
 Goal=Less than 10 second break in every 2 minute cycle of
CPR
 30:2
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100 compressions/min =18s for compressions
5 second break for ventilations every 30 compressions?
18 of every 23s in active compression is 78%
NOT counting other breaks in CPR
 Pit Crew
 Continuous compressions w/asynchronous ventilation
 10s break every 2 min is 92%
 5s break every 2 min is 96%
PIT CREW CPR
PIT CREW CPR
CARDIOCEREBRAL RESUSCITATION
 Components
 1. Continuous chest compression without ventilations
 2. Deemphasizing –intubations, ventilations but emphasize CCC early
defibrillation and early administrations of EPI
VENTILATIONS
Hyper ventilati on
Resqpod
Capnnometr y
readings
OXYGEN
 Hyperoxia
 AMI-Increase systemic Vascular resistance, decrease cardiac output
and stroke volume
 Cardiac arrest-poor neurological outcomes
 COPD-Austin COPD study
 2% vs 9%
 Goal
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Ischemia and infarction aim for mid 90 but not 98 -100
94-95% stable
89-92% COPD
Avoid high flow 02 in patients with stable saturations
PASSIVE OXYGENATION
 Dif fusion of 02
 Decreasing intra-thoracic pressure
 NC during intubation or NRB during CPR
ETI VS. SGA
 Resuscitations Outcomes Consortium (ROC)
 ETI VS SGA 8,847 patients underwent ET compared to 1,968
 Neurological intact ET=4.7 and SGA=3.9
 Japanese 2013 study
 ETI and SGA new skills
 BVM=2.6 times better survival
 Comparable to the CARES study
 SGA first line airway in Cardiac arrest
 Understanding the ef fects of Positive Pressure Ventilations
 Bottom Line-What do you do?
 Pre-hospital Airway management and Neurological outcomes
are linked the question is why?
HYPERVENTIALTION
 Detrimental impact
 Common in hospital and pre -hospital
 Ef fects
 Tools
RESQ-POD
 What is it?
 “The ResQPOD is an impedance threshold device (ITD) that provides
Perfusion on Demand (POD) by regulating pressures in the thorax
during states of hypotension.
 Early studies
 Pirallo compared to “sham” device
 Improved BP in arrest victims
 ROC Primed-no improvement in outcomes
 Increased Resuscitation results when used with other Tech.
CAPNOGRAPHY READINGS
 What are the reading associated with ROSC?
 Spontaneous increase to values between 35-45
 <less than 10 ROSC unlikely
 AHA recommendations:
 Confirm placement of ET tube and monitor waveform.
 Monitor the adequacy of ventilation and oxygenation.
 Monitor CPR quality, optimize chest compression, detect ROSC
 if waveform capnography is less than 10mm hg improve CPR.
DEFIBRILLATION
Sequential
defibrillation
Cardiac
rhythm review
SEQUENTIAL DEFIBRILLATION
 Double defib?
 Last ditch effort
 Continuous V-tach/V-fib
 The science
 The how
HANDS ON DEFIBRILATION
 Resuscitation 2014
 Electrical exposure risk associated with hands -on defibrillation
 Study outcomes
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Safety of HOD not known
If you do make sure you are wearing gloves
Do not place hands on pads
HOD or not minimize pre-shock pause
Large real life study needed
DRUGS
Old standbys
EPI
 Central ROLE???
 Japanese study 2007-2010
 2,000 v-tach and v-fib/10,000 PEA and Asystole
 Did receive ROSC 17 vs 13.4 % and 4 and 2.4%
 Poor neurological outcomes
 Australians study 2011
 ROSC but no changes in hospital discharge
 Other Drugs with EPI
 Vasopressin and steroids
 Greek Study in VSE (vasopressin, steroids, epi)
 ROSC and hospital charge 13.9% vs 5.1%
UK STUDY
 University of Warwick
 Poss. published 2019?
 Public out cry
AFTER CARE
Theureptic
hypothermia
Reprofusion
centers
THERAPEUTIC HYPOTHERMIA
2010
 AHA “ The
2010 AHA Guidelines for CPR and ECC recommends cooling comatose (i.e.
lack of meaningful response to verbal commands) adult patients with ROSC after out of-hospital VD cardiac arrest to 32 to 34 degrees for 12 -24 hours. Healthcare
providers should also consider induced hypothermia for comatose adult patients with
ROSC after in-hospital cardiac arrest of any initial rhythm or after out -of-hospital
cardiac arrest with an initial rhythm of PEA or Asystole” 2010 ACLS provider manual”
 Science= Decrease or suppress many of the chemical reactions that
lead to cell death/Decrease Cerebral Met. Rate
 2014
 JAMA-Effect of Pre-hospital Induction of Mild Hypothermia on Survival
and Neurological Status Among Adults with Cardiac Arrest
Randomized Clinical trial
 Outcomes
 No improvement in any Neuro status group
 EMS group increase in re-arrest and pulmonary edema
 What is Not said-Should we cool or not cool to 33 C/Difference in
Urban Vs. Rural.-Currently TH exact role unknown
REPERFUSION CENTERS
 Evidence for taking patients to centers where they can
perform angiography (PCI) and hypothermia.
 “organized post-arrest care with an emphasis on multi disciplinary programs that focus on optimizing hemodynamic,
neurologic, and metabolic function may improve survival to
hospital discharge among victims who achieve ROSC following
cardiac arrest either in -or out of hospital” Jems 2012 EMS
State of the Science
 Bypassing closer hospitals? Page 28 ACLS provider manual
 ECMO example from Jems
FIELD TERMINATION
 AHA ACLS
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ROSC?
Presence of reliable data indicating death
DNR
Consider other issue drug overdose and hypothermia
Not every patient should be transported (P.91 Acls)
Capnography >10mg
 Resuscitating beyond the 25 minute mark
 Standard in ACLS
 WHAT IS THE NEUROLOGICAL OUTCOME OF THESE PATEINTS?
 CPC values of 1 or 2
 Better question is what is the point for ROSC and good neurlogical
outcomes
GETTING THE CPR MESSAGE OUT
 TAKE 10 is a community -focused ef fort to improve bystander
CPR rates and thus improve survival. Learning chest
compression only CPR for adults is simple. TAKE 10 is a 10
minute training session that teaches compression only CPR.
https://www.youtube.com/watch?v=Rkryc2
5Qsm8
TAKE AWAY MESSAGES
 Change is coming everyday whether we like it or not
 CPR needs to be performed flawlessly
 Focus on minimizing all delays i.e. charging, time off chest
 EPI role in arrest remains unknown
 O2 is not benign drug.
 Therapeutic hypothermia doesn’t appear to have any proven
benefits it may be started at the hospital.
THE END
HYPOTHERMIA PROTOCOL
 Example Greater Miami Valley EMS protocols for the treatment
of ROSC.
 See handouts
 Ice packs/chilled fluid