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High Performance CPRSan Luis Obispo County EMS Agency
Thank you to our sponsors!!!
Emergency Medical Services Fund
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)
• 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 SLOo Increase overall survival rate through – public education, early
911, use of AED, and HPCPRo Increase the number of patients with shockable rhythm with
bystander CPR and HPCPRo Increase out of hospital survival for shockable rhythms that
meet the standards being seen in other HPCPR programs
Objectives for today
• History• Science• Elements of HPCPR
• CPR Rate/Depth/Recoil• Minimal Interruptions• Airway management
• Translating knowledge into practice• Hands-on practice• Simulation
• Review
HISTORY
1961A. Peter Safar, 1950s
B. Early symposium on CPR
A B
CPR is over 50 years old, but recent changes have shown increases in survival
Figure 2: Temporal Trends in OHCA Survival Over Time (Sasson et. al. Circuation: Cardiovascular Quality and Outcomes Nov. 2009.)
1960 >2010 What have we learned about CPR?
History has provide a better understanding of CPR
• 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
The Result > HPCR or PIT Crew Model
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
GOAL:MINIMIZE INTERRUPTIONS
Common “Tasks” > Interruptions
• Airway interventions and IVs• Ventilations• Pulse checks• Rhythm analysis• Defibrillation• Changing compressors• Patient movement
Interruptions - Old vs New
• 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
5 sec
80
160
mm
Hg
Time (sec)
40
120
0
Coronary Perfusion Pressures
Cerebral Perfusion Pressures
No Cerebral Perfusion
Single rescuer performing 30:2 with realistic 16 sec. interruption of chest compressions for MTM
ventilations
Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525
0
5 sec
80
160
mm
Hg
Time (sec)
40
120
Coronary Perfusion Pressures
Continuous Cerebral Perfusion Pressures
Single rescuer performing continuous chest compressions
Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525
Perfusion with continuous compressions
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
Sh
ock
su
cces
s, p
erce
nt
90%
10%
55%64%
p=0.003
Defibrillation success and pre-shock pauses
Edelson et al, 2006
HPCPR Goal: Less than 5-10 second break
in every 2 minute cycle of CPR
GOAL:QUALITY CPRRATE/DEPTH/RECOIL
Rate Matters
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)
Nu
mb
er
of
30 s
ec
seg
men
ts300
250
200
150
100
50
0
n=1626 segments
Chest compression rates of auto pulse devices
Abella et al, 2005
DEPTH
40
32
24
16
8
0
1 2 3 CPR duration, min
CP
P, m
m H
g
ICCM, 2005
2 inches vs 1.5 inchesSurvival:
100%
15%
Survival better with compressions >2 inches deep
Sh
ock
su
cces
s, p
erce
nt
Compression depth, inches
n=10 n=5n=14n=13
p=0.02
Shock success by compression depth
Edelson et al, 2006
RECOIL ORCOMPRESSION FRACTION
How Does CPR Cause Blood Flow?Thoracic Pump
+
Ensure Total Chest Recoil with:
1) Lifting palm during compressionsor
2) Using feedback device
+
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)
• Trauma• Drowning• Hypoxic Cardiac Arrest• Suspected Respiratory Cause• Overdose, etc.
86%
13%
0%
20%
40%
60%
80%
100%
% survival
12 30
# ventilations per minute
p= 0.006
Aufderheide et al. Circulation 2004; 109:1960-5
Hyperventilation during CPR = Decrease in Survival
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
35%
30%
25%
20%
15%
10%
5%
0%
17.7%
33.7%
Su
rviv
al to
Hosp
ital D
isch
arg
e
Std-CPR COCPR
Survival after Bystander CPR for OHCA in Arizona (2005 to 2010)Compression Only CPR (COCPR) Advocated and Taught
Bobrow, et al. JAMA 2010:304:1447-1454
P < 0.001
Witnessed/Shockable
7.8%
Std-CPR
13.3%
COCPR
A. B.All OHCA
AOR 1.6 (95% CI, 1.08-2.35)
Bystander contacted 9-1-1
standard CPR (n=960) chest compression alone (n=981)
Dispatcher-assisted hands-only CPR
2010
Survival to DC11.5% 14.4%
HP CPR (Pit) Crew
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.
EMS Can Further Improving Cardiac Arrest Outcomes?
Key Elements to HPCPR
• 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
Rate indicator
Perfusion performance
indicator
Depth indicator
Release
ETCO2
CPR Quality
HPCPRIntegrating 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
POI
P1 P2
Position 1 (P1) -Initial Team Leader
• 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)
• 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
AED
2 Person BLS
P3
P1 P2
AED/ Monitor
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• Provides respirations on upstroke of 10th compression and
keeps count of compressions
Position 2 (P2)
• 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
3 Person
P3
P1 P2
AED/ Monitor
Position 1 (P1) • Initiate compressions 110/min• Alternates compressions with P2 at 200 compression • When not doing compressions and keeps count of
compressions
Position 2 (P2) • Activates Metronome• Applies and operates AED /Monitor• Ventilates 200-400cc every 10 compression• Alternates with P1 at 200 compression /keeping count
4 Person BLS/ALS
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
P4 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
How long …
Stay on scene and work the code until:
• 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 non-viable
patient• Exceptions: children and other causes of cardiac arrest i.e. trauma,
drowning, OD, etc.
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:
• Measure Outcomes• Provide Feedback• Continuous Improvement Program• Practice regularly
Take Home Points
• Cardiac Arrests Outcomes Can Improve!• BLS CPR quality makes the biggest impact
• 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
DEATH TELLING
Death telling
• Assign someone to be the primary communicator with the family
• Be honest and direct• Ask about
support/resources
Time to practice….