Updated importance of CPR lecture I gave for the Eastern OR EMS Conference http://easternoregonems.com/ Facebook Page: https://www.facebook.com/EasternOREMS?ref=br_tf

1. Importance of CPR
Robert S. Cole

2. Contact Information
•
•
•
•
•
Steve Cole
EMS for 23 years
Ada County Paramedics 15 plus years
CWI
croaker260@gmail.com

3. Credit where Credit is Due
• Adapted from presentation by Ahamed Idris, MD,
– Professor of Emergency Medicine University of Texas
Southwestern Medical Center at Dallas

4. Special Thanks
• Dr. Peter Safar
• Father of Resuscitation
medicine
• Helped develop CPR
• Directly responsible for the
research used in therapeutic
hypothermia.

5. RESCOURCES
Seattle/KCM1 Resuscitation
Academy
Coursera Online Courses

6. AHA Resources
Beware of this
Start with this:

8. • 2010 ECC Guidelines
– http://circ.ahajournals.org/content/122/18_suppl_3.toc

9. Objectives
•
•
•
•
•
•
•
Importance of maximizing CPR.
Why compression:ventilation ratio 30:2 ?
Complete chest wall recoil
Danger of hyperventilation
CPR First vs shock first
1 shock vs 3 shocks
Minimize delay to shock

10. Why I am doing this lecture….
Why I am doing this lecture….

11. A need for change…
• Approximately 350,000 persons die from out-of-hospital cardiac
arrest each year in North America.
• Survival rate is poor among these patients, and most do not
survive to hospital discharge.
• New research suggests CPR has a much greater impact on
cardiac arrest survival than previously thought.
• Other research suggests that an impedance threshold device
(ITD) may improve outcome.

12. CPR in Hollywood…
• ROSC (Getting a pulse back)
75%
• discharged neurologically Intact 67%

13. CPR in Real Life
• ROSC between 0.1% and 49%
– 3-7% typical
• Survival to Hospital Admission: 23%
• Survival to Discharge : 7.6%
– THIS HAS NOT IMPROVED SIGNIFICANTLY IN 30YEARS!
• Good Neurological Outcome: 0.1% and 30%
Predictors of Survival From Out-of-Hospital Cardiac Arrest: A Systematic Review
and Meta-Analysis
Comilla Sasson, Mary A.M. Rogers, Jason Dahl, and Arthur L. KellermannCirc
Cardiovasc Qual Outcomes. 2010;3:63-81, published online before print November 10
2009, doi:10.1161/CIRCOUTCOMES.109.8895 6

14. Today: Nearly everyone dies….

15. But there is hope…
Howard Snitzer, 59, survived 96 minutes of CPR with no neuro Deficits.

16. Breaking the Barrier
• 50% ROSC in VF arrest?
– August 5, 1967 Bellfast Scotland
• 100% ROSC, 50% survival to discharge
• (random Fact: This was the issue that Dr. Ashbaugh first described
ARDS in as well)
– Seattle / KCM1 in 2011
A MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF MYOCARDIAL INFARCTION
J.F. Pantridge M.C., M.D. Belf., F.R.C.P.,J.S. Geddes M.D., B.Sc. Belf.
The Lancet - 5 August 1967 ( Vol. 290, Issue 7510, Pages 271-273 )
DOI: 10.1016/S0140-6736(67)90110-9

17. Importance Of CPR
10-20% of normal blood flow to the heart
20-30% of normal blood flow to the brain

18. 3 Phase Model

19. Cardiac Output During CPR

21. KEY POINT:
CPR, not PARAMEDICS, save lives in most
Cardiac Arrests

22. Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure. CPP is “roughly” half Aortic Pressure.

23. Understanding Chest Compressions
Compression
• Increased intrathoracic pressure
• Compression of heart and lungs
Decompression (recoil)
• Decreased intrathoracic pressure
• Refilling of heart and lungs
Complete chest recoil is critical

24. ROSC Associated with CPP

25. Benefit of Continuous Chest Compressions

26. Intra-thoracic Pressure and CPR?

27. New Cardiac Guidelines (2005)
• Rate of 100/minute.
• Depth of 1 1/2–2 inches
– (or more in larger people).
• Complete chest recoil after each compression.
• Ventilation (less is more).
– No more than 10 ventilations per minute.
– Inspiration phase of no more than 1 second
• Minimize interruptions in chest compressions.
• Rotate compressors every 2–3 minutes to minimize fatigue.

28. 2005 to 2010 changes…
Component of CPR
2005 ECC
recommendations
2010 ECC
Recommendations
DEPTH OF
COMPRESSION
1 ½ - 2 inches
Greater than 2 inches
RATE
100 /MINUTE
At least 100 /MIN
VENTILATION
8-10 /MINUTE
8-10 /MINUTE
CHEST RECOIL
100%
100%
INTURUPTIONS
Minimized
Less than 10 seconds
goal

29. Who does good CPR?

30. Answer: NO ONE!
Studies showed…
• Chest compressions were not delivered about half of the
time (too much “hands off”).
• Most compressions were not deep enough.
Quality of Cardiopulmonary
Resuscitation During Out-of-Hospital
Cardiac Arrest
Wik, et al. JAMA 2005

31. THE PAINFUL TRUTH
•Perceived performance does not always match observed performance.
•Aufderheide et al. showed that duty cycle, chest compression depth and
complete recoil were performed significantly less well when directly observed
than EMT perceptions of their performance.
•Wik et al. showed that chest compression rate and depth were both
significantly below AHA guidelines by trained EMS providers, and no flow time
(when there was neither a pulse nor CPR being given) was almost 50% in
directly observed performance evaluations.
•The likelihood of ROSC increases significantly with higher mean chest
compression rate (in a hospital study 75% of patients achieved ROSC with 90
or more chest compressions/minute compared to only 42% with 72 or fewer
chest compressions/minute).

32. IMPORTANT POINT!
• RATE
5 KEY
ASPECTS
OF
GOOD
CPR!
• DEPTH
• RELEASE
• UNINTERRUPTED
• DECREASED
VENTILATION

33. Answer: NO ONE!
Studies showed…
• Chest compressions were not delivered about half of the
time (too much “hands off”).
• Most compressions were not deep enough.
Quality of Cardiopulmonary
Resuscitation During Out-of-Hospital
Cardiac Arrest
Wik, et al. JAMA 2005

34. Compression DEPTH
• Target = 38-51 mm with complete release
• Reality = only 27% achieve target
Quality of Cardiopulmonary
Resuscitation During Out-of-Hospital
Cardiac Arrest
Wik, et al. JAMA 2005

35. No-Flow Ratio (Interruption of CPR)
• Target = less than 20%
• Reality = 48%
Quality of Cardiopulmonary
Resuscitation During Out-of-Hospital
Cardiac Arrest
Wik, et al. JAMA 2005

36. Compression Rate
• Target = ~100/min with complete release
• Reality = 60/min due to “No Flow Ratio”
Quality of Cardiopulmonary
Resuscitation During Out-of-Hospital
Cardiac Arrest
Wik, et al. JAMA 2005

37. Compression Rate…
Percent segments
within 10 cpm
of AHA Guidelines
31 %
36.9%
Abella, et al 2005 Circulation

38. Compression Rate…

39. Barriers to staying on
the chest…
• Pausing for procedures
– intubation, IV, pulse check, etc.).
•
•
•
•
Pausing for rhythm analysis.
Pausing after shock to await post-shock rhythm.
Pausing to charge, clear, and shock.
Unaware of importance of CPR in “big picture”

40. Importance of complete recoil

41. Get EVERY Compression Right
Critical pressure for
ROSC
(Paradis et al. JAMA
1990;263:3257-8)
Abella, et al 2005
Circulation

42. Cerebral Perfusion Pressures and CPR
Abella, et al 2005
Circulation

43. Current Guidelines for Ventilation
• CPR with Advanced Airway: 8 – 10
breaths/minute
• Post-resuscitation: 10 – 12/min

44. Compression-Ventilation Ratio
•
•
•
•
•
Ventilation rate = 12/min
Compression rate = 78/min.
Large amplitude waves = ventilations.
Small amplitude waves = compressions.
Each strip records 16 seconds of time

45. Reality Sucks…
• Compression: Ventilation Ratio 2:1
• 47-48 Breaths a minute
47 Nails in a coffin!

46. Prolonged Ventilations
•
•
•
􀂃 Ventilation Duration = 4.36 seconds / breath
􀂃 Ventilation Rate = 11 breaths / minute
􀂃 % time under Positive Pressure = 80%

47. Everyone sucks!
• Milwaukee
– Mean Ventilation Rate:
– AFTER 2 months training:
• Dallas
• Tuscan
• Chicago
37/minute
22/minute
30/minute
34/minute
>30/minute

48. Effect of Vent. Rate on CPP
12 RR /minute
CPP 23.4 ± 1.0mmHg
MIP 7.1 ± 0.7 mmHg/min
20 RR /minute
CPP 19.5 ± 1.8 mmHg
MIP 11.6 ± 0.7
mmHg/min
30 RR /minute
CPP 16.9 ± 1.8 mmHg
MIP 17.5 ± 1.0
mmHg/min

49. Aware of importance of CPR?
1975
1978
1980s and 1990’s
King County/Seattle Medic One EMS System Data, Cobb,

51. CPR FIRST?
% ROSC

52. CPR FIRST BEFORE DEFIB?
• The rate of survival improved (24 percent to 30 percent) when
CPR was initiated prior to external defibrillation, especially in
patients with delayed initial response intervals (longer than 4
minutes): 27 percent with CPR versus 17 percent without CPR.
The overall proportion that survived with favorable neurologic
recovery also improved from 17 percent to 23 percent.
Cobb LA et al. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-ofhospital ventricular fibrillation.JAMA 1999 Apr 7 281 1182-1188.

53. CPR IMPROVING DEFIB?

55. CPR Improving EPI?

59. WHERE DOES THE AIRWAY FIT IN?

60. • Hands off period for ETT during CPR estimated at 47
seconds per attempt, with some patients losing over 2
minutes of hands off time!
– (Wang, Simeone, Weaver, & Callaway, 2009).

61. Intubate DURING CPR !
• Minimal / no interruption of
compressions
• More time (up to 2 minutes) to
get the tube = better 1st pass
success

62. Why not a supra/peri-glottis airway?
• large study , 2005-2007, over
131K patients
• Compared LMA, ETT, and
EOA

63. Why not a supra/peri-glottis airway?
• “Prehospital use of supraglottic airway devices was
associated with slightly, but significantly, poorer
neurological outcomes compared with tracheal intubation,
but neurological outcomes remained poor overall.”

64. Why not a supra/peri-glottis airway?
• “ EMT-I placed LMA during ambulance transport was
associated with worsened OHCA survival to discharge
than BVM. Outcomes were similar between EMT-I
endotracheal intubation and bag-valve-mask ventilation.”

65. Cric Pressure (Really???)
• Cricoid pressure in non-arrest patients may offer
some measure of protection to the airway from
aspiration and gastric insufflation during bag-mask
ventilation.
• However, it also may impede ventilation and
interfere with placement of a supraglottic airway or
intubation.
• If cricoid pressure is used in special circumstances
during cardiac arrest, the pressure should be
adjusted, relaxed, or released if it impedes
ventilation or advanced airway placement.
• The routine use of cricoid pressure in cardiac arrest
is not recommended (Class III, LOE C).

66. FiO2 (During Arrest)
• Use of 100% inspired oxygen (FIO2 1.0) as soon as it
becomes available is reasonable during resuscitation from
cardiac arrest (Class IIa, LOE C).

67. FiO2 (post arrest)
• Increasing Data that hyper-oxia may increase incidence of poor
neurological outcomes and increased pulmonary injury.
– Hyper-oxia defined as PaO2 >300 cm H2O
• Exact FiO2 recommendations have not been determined.
• In the post arrest phase, if equipment is available, titration of FiO2
to SPO2 94%-99% is recommended (Class I, LOE C).
– Dependent on individual factors
• This may not apply to other life-threatening states.

68. Passive O2 delivery during arrest
• Passive O2 delivary via ETT (Boussignac tube, or standard ETT) as well as via NRB, has
been reviewed.
• In theory, because ventilation requirements are lower than normal during cardiac arrest,
oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of
cardiac arrest with a patent upper airway.
• The studies involved resulted in improved outcomes., but it is unsure what role (if any)
passive O2 had.
• At this time there is insufficient evidence to support the removal of ventilations from
CPR performed by ACLS providers.

69. NC at 15 LPM?
• Principle of “Apniec Diffusion”
• FiO2 w/ NRB at 60-70% with 15 LPM
alone.
• Using high flow via NC will improve SPO2
over NRB alone
– Works best with bilat NPA’s
• Oxygenation can be maintained in nonbreathing humans for 100 minutes through
apneic diffusion, even as carbon dioxide
builds up in the blood.

70. CPR: Whats Next?

71. • 90% of all changes to 2010 ECC are right in the BLS
segment.
• Builds on and further enhances the changes and research
discussed in the 2005 guidelines.
• COMPRESSIONS are the single most emphasized
segment of resuscitation.

72. Hands
Only
CPR???
• Single biggest change
• “Hands Only CPR” AKA:
Compression only CPR
for lay persons and non
HCP first responders.

74. KEY POINT:
• HANDS ONLY CPR MAY IMPROVE
ROSC BY 7% OVER TRADITIONAL CPR

75. New CPR Guidelines

76. Traditional Healthcare Version

77. CAB???
• Sequence change to chest compressions before rescue
breaths (CAB rather than ABC)
• This is expected to reduce time from assessment of
responsiveness to first compression by 30 or more
seconds.
• This reduction in time during this critical period early in the
arrest is expected to improve survival and also response
to first shock.

78. Pulse Check?
• Studies have shown that both lay rescuers and healthcare
providers have difficulty detecting a pulse.
• The lay rescuer should not check for a pulse and should assume
that cardiac arrest is present if an adult suddenly collapses or an
unresponsive victim is not breathing normally.
• Healthcare providers also may take too long to check for a pulse.
The healthcare provider should take no more than 10 seconds to
check for a pulse and, if the rescuer does not definitely feel a
pulse within that time period, the rescuer should begin CPR.

79. Look, Listen, and Feel?
• Confusion in Agonal Respirations vs. Good Respirations
• “Look , Listen, and Feel” de- emphasized

80. ADJUNCTS IN CPR

81. CPR Prompts

84. CPR Feedback?
CPR FEEDBACK?

85. Adjuncts to Circulation
• Impedance threshold
device (ITD)
– Valve device placed
between endotracheal
tube and bag-mask
device
– Limits air entering
lungs during recoil
phase between chest
compressions
Courtesy of Advanced Circulatory Systems, Inc.

86. Impedance Threshold Device (ITD)
•
•
•
•
•
Used both with ETT, Face
Mask, and other advanced
Airways.
The ITD limits air entry into the
lungs
during the decompression
phase of CPR, creating
negative intrathoracic pressure
and improving venous return to
the heart and cardiac output
during CPR.
Major reviews have shown
some survival to hospital
improvement, but this may be
multi-factorial.
The ITD may be considered by
trained personnel as a CPR
adjunct in adult cardiac arrest
(Class IIb, LOE B).

87. Active Compression-Decompression CPR
(ACD-CPR)
• Small studies showed
improvement, but a
Cochrane Meta- review of
over 1000 patients did
not.
• ACD-CPR may be
considered for use when
providers are adequately
trained and monitored
(Class IIb, LOE B).

88. • Mechanical piston
device
– Depresses
sternum via
compressed gaspowered plunger
Courtesy of Jolife AB
Courtesy of ZOLL
Adjuncts to Circulation
• Load-distributing
band CPR or vest
CPR
– Composed of
constricting band
and backboard

90. Mechanical Piston Devices
• L.U.C.A.S., THUMPER, ETC
• In 3 Studies the use of a mechanical
piston device for CPR improved endtidal CO2 and mean arterial pressure
during adult cardiac arrest
resuscitation.
• No long term benefit over manual CPR
discovered (yet)
• There is insufficient evidence to
support or refute the routine use of
mechanical piston devices in the
treatment of cardiac arrest.
• Use of such devices during specific
cercumstances when manual CPR is
difficult may be done (Class IIb, LOE
C).

91. Load-Distributing Band CPR or Vest CPR
(LDB-CPR)
• Auto-Pulse is the most common
• Initial repots were very positive,
however a large study showed poor
neurological outcomes.
• Further studies pending.
• The LDB may be considered for use
by properly trained personnel in
specific settings for the treatment of
cardiac arrest (Class IIb, LOE B).
• However, there is insufficient
evidence to support the routine use of
the LDB in the treatment of cardiac
arrest

92. Therapeutic Hypothermia?

93. Therapeutic Hypothermia?
• CLASS I Intervention for witnessed VF /VT arrests
– Class IIa intervention or asytolic and un-witnessed arrests.
• MILD Hypothermia
– Exact temp debatable
– 33 C (93 F) to 36 C (96 F)
• Significantly improves outcomes
• Only works if continued by hospitals
– New York FD/EMS experience

94. EMS hypothermia not useful?
• Seattle/KC trial – 1,359 patients
• Short transport times, ALL patients in this study received
in hospital cooling
• Did not evaluate systems with longer transport times, less
robust in hospital SCA response
• Did not evaluate likely hood of patients receiving cooling
without pre-hospital cooling (FDNY experience)
Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction
of mild hypothermia on survival and neurological status among
adults with cardiac arrest: A randomized clinical trial. JAMA.
2013

95. The Future???
• Increased focus on the “Metabolic Phase”
• Cardiac ByPass
• Mitochondrial medicine
– Stabilizing the “Apotic Switch”
• Ion Channel
• Deep Hypothermia
– Trauma Studies Ongoing

96. PIT CREW CPR

100. Improved
survival
Intubation
Rapid
rhythm
analysis
Switch
compressor
s every 2
min.
Compress
Minimize
pauses
Hover hands
Minimize
interruptions
Paramedic
Advanced Life
Support
IV
placement
Administer
drugs
Prioritize
compressions
C-A-B
Full recoil
> 2 inches
EMT CPR Foundation
Rate between
100 and
120/min

101. 1
2
3
4
5
6

102. CPR 1
AIRWAY
VENTILATION
1
2
3
CPR 2
/AED

103. 1
2
3
4
5
6

104. CPR 1
AIRWAY
VENTILATION
2
BOSS
4
1
6
AIRWAY
ASSISTANT
5
CPR 2
3
ACCESS
MEDS
MONITOR

105. PARAMEDICS: GIVE AWAY THE TUBE!!!

106. Checklist
Medicine?
• Derived from the Airline
Industry
• Oh Crap checklist, not step by
step checkists

107. •EMTs own CPR / Medics Own “Everything else”
•Minimize interruptions in CPR at all times
•Ensure proper depth of compressions (>2 inches)
•Ensure full chest recoil/decompression
•Ensure proper chest compression rate (100-120/min)
•Rotate compressors every 2 minutes
•Hover hands over chest during shock administration
and be ready to compress as soon as patient is cleared
•Intubate or place advanced airway with ongoing CPR
•Place IV or IO with ongoing CPR
•Coordination and teamwork between EMTs and paramedics

108. “It is up to us to save the world.”
- Peter Safar