2014 importance of cpr eastern or ems conference

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Updated importance of CPR lecture I gave for the Eastern OR EMS Conference

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  • The team reported the initial results of their program in the August 5, 1967 issue of The Lancet; their findings on 312 patients covered a 15-month period. Half the patients had MI and there were no deaths during transportation. Of ground-breaking importance was the information on 10 patients who had cardiac arrest. All had ventricular fibrillation; six arrests occurred after the arrival of the MCCU, and four occurred shortly before arrival of the ambulance. All 10 patients were resuscitated and admitted to the hospital. Five were subsequently discharged alive (ref). The article has historical importance because it served to stimulate pre-hospital emergency cardiac care programs throughout the world. As an historical footnote, August 1967 is exactly 200 years to the month from the founding of the Amsterdam Rescue Society. The rescue effort that began in 1767 in Amsterdam as an attempt to resuscitate drowning victims (the sudden death of the 18th century) finally culminated two centuries later in Belfast with a successful way to achieve resuscitation for cardiac arrest (the sudden death of the 20th century).The Lancet, Volume 290, Issue 7510, Pages 271 - 273, 5 August 1967Next Article>doi:10.1016/S0140-6736(67)90110-9Cite or Link Using DOIA MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF MYOCARDIAL INFARCTIONJ.F. Pantridge M.C., M.D. Belf., F.R.C.P. , J.S. Geddes M.D., B.Sc. Belf.AbstractThe risk of death from myocardial infarction is greatest in the twelve-hour period after the onset of symptoms. Despite this, the hospital admission of a large proportion of patients is delayed for more than twelve hours, and many die in transit to hospital. A scheme has been described involving the use of a highly mobile unit which enables intensive care to reach the patient when he is at most risk. The unit has been used in the transfer of patients to hospital. No death has occurred in transit in a fifteen-month period. Ten examples of successful resuscitation outside hospital are reported. 5 of these patients are now alive and well. Thus it has been shown perhaps for the first time that the correction of cardiac arrest outside hospital is a practicable proposition.CARDIAC DEPARTMENT, ROYAL VICTORIA HOSPITAL, BELFAST 12, United Kingdom
  • 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).
  • Ventilations✦ Ventilation is believed to be a vital component of resuscitation, but too much of agood thing (hyperventilation) can decrease survival.✦ Long ventilations (greater than the 1 second per breath recommended by AHA)potentially increases the pause (during 30:2) and the amount of time spent withoutchest compressions.✦ Even when not interrupting CPR (such as in an intubated patient), excessiveventilation prevents the development of negative intrathoracic pressure during thedecompression phase of CPR, which impedes blood return (filling) to the heart.High Performance CPR9
  •  EMS pulse checks are often inaccurate and may result in interruptions of 30 seconds or longer in chest compression (Eberle et al., 1996).  AED rhythm determination algorithms can result in chest compression interruption of a similar duration (Rea, Shah, Kudenchuk, Copass, & Cobb, 2005). 
  • Resuscitation Outcomes Consortium data shows that the first intubation attempt results in a 47-second chest compression interruption with the average patient losing more than 2 minutes of chest compression time during a resuscitation attempt due to intubation attempts (Wang, Simeone, Weaver, & Callaway, 2009).
  • J Emerg Med. 2013 Feb;44(2):389-97. doi: 10.1016/j.jemermed.2012.02.026. Epub 2012 Apr 26.Comparison of neurological outcome between tracheal intubation and supraglottic airway device insertion of out-of-hospital cardiac arrest patients: a nationwide, population-based, observational study.Tanabe S1, Ogawa T, Akahane M, Koike S, Horiguchi H, Yasunaga H, Mizoguchi T, Hatanaka T, Yokota H, Imamura T.Author informationAbstractBACKGROUND:The effect of prehospital use of supraglottic airway devices as an alternative to tracheal intubation on long-term outcomes of patients with out-of-hospital cardiac arrest is unclear.STUDY OBJECTIVES:We compared the neurological outcomes of patients who underwent supraglottic airway device insertion with those who underwent tracheal intubation.METHODS:We conducted a nationwide population-based observational study using a national database containing all out-of-hospital cardiac arrest cases in Japan over a 3-year period (2005-2007). The rates of neurologically favorable 1-month survival (primary outcome) and of 1-month survival and return of spontaneous circulation before hospital arrival (secondary outcomes) were examined. Multiple logistic regression analyses were performed to adjust for potential confounders. Advanced airway devices were used in 138,248 of 318,141 patients, including an endotracheal tube (ETT) in 16,054 patients (12%), a laryngeal mask airway (LMA) in 34,125 patients (25%), and an esophageal obturator airway (EOA) in 88,069 patients (63%).RESULTS:The overall rate of neurologically favorable 1-month survival was 1.03% (1426/137,880). The rates of neurologically favorable 1-month survival were 1.14% (183/16,028) in the ETT group, 0.98% (333/34,059) in the LMA group, and 1.04% (910/87,793) in the EOA group. Compared with the ETT group, the rates were significantly lower in the LMA group (adjusted odds ratio 0.77, 95% confidence interval [CI] 0.64-0.94) and EOA group (adjusted odds ratio 0.81, 95% CI 0.68-0.96).CONCLUSIONS: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.Copyright © 2013 Elsevier Inc. All rights reserved.PMID: 22541878 [PubMed - indexed for MEDLINE]National review 2005-2007 in over 131K patients
  • Out-of-hospital airway management and cardiac arrest outcomes: a propensity score matched analysis.Shin SD1, Ahn KO, Song KJ, Park CB, Lee EJ.Author information1Department of Emergency Medicine, Seoul National University College of Medicine, Republic of Korea. shinsangdo@medimail.co.krAbstractOBJECTIVE:It is unclear whether advanced airway management during ambulance transport is associated with improved out-of-hospital cardiac arrest (OHCA) outcomes compared with bag-valve mask ventilation (BVM). This study aimed to determine whether EMT-intermediate ETI or LMA is associated with improved OHCA outcomes in Korea.METHODS:We used a Korean national OHCA cohort database composed of hospital and ambulance data. We included all EMS-treated by level 1 EMTs (EMT-intermediate level) and OHCA with presumed cardiac etiology for the period January 2006-December 2008. We excluded cases not receiving continued resuscitation in the emergency department (ED), treated by level 2 EMT, as well as those without available hospital outcome data. The primary exposure was airway management technique during ambulance transport (endotracheal tube (ETI), laryngeal mask airway (LMA) or bag-valve-mask ventilation with an oropharyngeal airway). The primary outcomes were survival to admission and survival to hospital discharge. We compared outcomes between each airway management group using multivariable logistic regression, adjusting for sex, age, witnessed, prehospital defibrillation, bystander cardiopulmonary resuscitation (CPR), call to ambulance arrival time to the scene, call to ambulance arrival time to ED, initial ECG, metropolitan (defined as population>1 million), and level of ED (higher versus lower level). We repeated the analysis using propensity-score matched subsets.RESULTS:Of 54,496 patients with OHCA, we included 5278 (9.7%). Overall survival to admission and to discharge was 20.2% and 6.9%, respectively. ETI and LMA were performed in 250 (4.7%) and 391 (7.4%), respectively. In the full multivariable models using total patients, adjusted survival to admission and discharge were similar for ETI and BVM: OR 0.91 (0.66-1.27) and 1.00 (0.60-1.66), respectively. Adjusted survival to admission and discharge were significantly lower in LMA than BVM: OR 0.72 (0.54-0.95) and 0.52 (0.32-0.85), respectively. In the full multivariable models using propensity matched samples, adjusted survival to admission and discharge were similar for ETI and BVM; OR 1.32 (0.81-2.16) and 1.44 (0.66-3.15), respectively. Adjusted survival to admission was similar for LMA and BVM: OR 0.72 (0.50-1.02). However, survival to discharge was significantly lower for LMA than BVM: OR 0.45 (0.25-0.82).CONCLUSIONS:In Korea, 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.Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
  • The quality of unprompted CPR in both in-hospital and out-of–hospital cardiac arrest events is often poor, and methods shouldbe developed to improve the quality of CPR delivered to victimsof cardiac arrest.73,91–93,287 Several studies have demonstratedimprovement in chest compression rate, depth, chest recoil,ventilation rate, and indicators of blood flow such as end-tidalCO2 (PETCO2) when real-time feedback or prompt devices areused to guide CPR performance.72,73,80,288–293 However, there areno studies to date that demonstrate a significant improvement inpatient survival related to the use of CPR feedback devicesduring actual cardiac arrest events. Other CPR feedback deviceswith accelerometers may overestimate compression depth whencompressions are performed on a soft surface such as a mattressbecause the depth of sternal movement may be partly due tomovement of the mattress rather than anterior-posterior (AP)compression of the chest.62,294 Nevertheless, real-time CPRprompting and feedback technology such as visual and auditoryprompting devices can improve the quality of CPR (Class IIa,LOE B).
  • Several studies have demonstrated improvement in chest compression rate, depth, chest recoil, ventilation rate, and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance. However, there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events. Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest. Nevertheless, real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa, LOE B).
  • Questioning Pre-hospital CoolingFrancis Kim, MD, of the University of Washington, Seattle (Seattle, WA), and colleagues randomized 1,359 patients resuscitated after cardiac arrest (42.9% with ventricular fibrillation [VF]) to standard care with (n = 688) or without (n = 671) prehospital cooling by infusing up to 2L of 4°C normal saline as soon as possible following return of spontaneous circulation. Patients were treated by paramedics in Seattle, WA, between December 15, 2007, and December 7, 2012. Mostly all patients resuscitated from VF and admitted to the hospital received cooling regardless of their randomization.The study was simultaneously published in the Journal of the American Medical Association.The intervention decreased mean core temperature by 1.20°C (95% CI -1.33°C to -1.07°C) and 1.30°C (95%CI -1.40°C to -1.20°C) in patients with and without VF, respectively, by hospital arrival and reduced the time to achieve a temperature of less than 34°C by about 1 hour compared with the control group.Nevertheless, rates of survival to hospital discharge and neurologic status denoting full recovery or mild impairment were similar between the study and control groups regardless of VF status (table 1).Table 1. Survival and Neurologic Status Cooling(n = 688)No Cooling(n = 671)P ValueSurvival to Hospital DischargeVFNo VF 62.7%19.2% 64.3%16.3% 0.690.30Neurologic Status of Full Recovery or Mild ImpairmentVFNo VF 57.5%14.4% 61.9%13.4% 0.69030The rate of deaths in the field were similar between the intervention and control groups (1.3% vs. 1.6%; P = 0.61). Those who underwent cooling experienced more rearrest in the field than controls (26% vs. 21%; P = 0.008), as well as increased diuretic use and pulmonary edema on first chest X-ray.Although cold normal saline reduced core temperature by hospital arrival, “prehospital cooling does not add benefit to hospital-initiated cooling,” Dr. Kim said. “The study findings do not support routine initiation of hypothermia using cold fluid in the prehospital setting.”Discussant MaaretCastrén, MD, PhD, of the Karolinska Institute (Stockholm, Sweden), congratulated the researchers on completing such a large study in the EMS setting.However, she said, results on the quality of the CPR and the variation in temperature were missing. In addition, Dr. Castrén listed factors that influence survival that were not included, such as identification by dispatcher and in-hospital post-resuscitation care.
  • The Importance of Good CPR✦ CPR is the foundation of the resuscitation arsenal.✦ High performance CPR improves the effectiveness of defibrillatory shock.✦ High performance CPR improves the effectiveness of medication treatments.How well do we do?✦ Perceived performance does not always match observed performance.✦ Aufderheide et al. showed that duty cycle, chest compression depth and completerecoil were performed significantly less well when directly observed than EMTperceptions of their performance.✦ Wik et al. showed that chest compression rate and depth were both significantlybelow AHA guidelines by trained EMS providers, and no flow time (when there wasneither a pulse nor CPR being given) was almost 50% in directly observedperformance evaluations.✦ The likelihood of ROSC increases significantly with higher mean chest compressionrate (in a hospital study 75% of patients achieved ROSC with 90 or more chestcompressions/minute compared to only 42% with 72 or fewer chest compressions/minute).High Performance CPR7
  • 2014 importance of cpr eastern or ems conference

    1. 1. Importance of CPR Robert S. Cole
    2. 2. Contact Information • • • • • Steve Cole EMS for 23 years Ada County Paramedics 15 plus years CWI croaker260@gmail.com
    3. 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. 4. Special Thanks • Dr. Peter Safar • Father of Resuscitation medicine • Helped develop CPR • Directly responsible for the research used in therapeutic hypothermia.
    5. 5. RESCOURCES Seattle/KCM1 Resuscitation Academy Coursera Online Courses
    6. 6. AHA Resources Beware of this Start with this:
    7. 7. • 2010 ECC Guidelines – http://circ.ahajournals.org/content/122/18_suppl_3.toc
    8. 8. 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
    9. 9. Why I am doing this lecture…. Why I am doing this lecture….
    10. 10. 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.
    11. 11. CPR in Hollywood… • ROSC (Getting a pulse back) 75% • discharged neurologically Intact 67%
    12. 12. 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
    13. 13. Today: Nearly everyone dies….
    14. 14. But there is hope… Howard Snitzer, 59, survived 96 minutes of CPR with no neuro Deficits.
    15. 15. 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
    16. 16. Importance Of CPR 10-20% of normal blood flow to the heart 20-30% of normal blood flow to the brain
    17. 17. 3 Phase Model
    18. 18. Cardiac Output During CPR
    19. 19. KEY POINT: CPR, not PARAMEDICS, save lives in most Cardiac Arrests
    20. 20. Understanding Coronary Perfusion Pressure Note this is Aortic Pressure. CPP is “roughly” half Aortic Pressure.
    21. 21. 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
    22. 22. ROSC Associated with CPP
    23. 23. Benefit of Continuous Chest Compressions
    24. 24. Intra-thoracic Pressure and CPR?
    25. 25. 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.
    26. 26. 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
    27. 27. Who does good CPR?
    28. 28. 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
    29. 29. 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).
    30. 30. IMPORTANT POINT! • RATE 5 KEY ASPECTS OF GOOD CPR! • DEPTH • RELEASE • UNINTERRUPTED • DECREASED VENTILATION
    31. 31. 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
    32. 32. 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
    33. 33. 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
    34. 34. 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
    35. 35. Compression Rate… Percent segments within 10 cpm of AHA Guidelines 31 % 36.9% Abella, et al 2005 Circulation
    36. 36. Compression Rate…
    37. 37. 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”
    38. 38. Importance of complete recoil
    39. 39. Get EVERY Compression Right Critical pressure for ROSC (Paradis et al. JAMA 1990;263:3257-8) Abella, et al 2005 Circulation
    40. 40. Cerebral Perfusion Pressures and CPR Abella, et al 2005 Circulation
    41. 41. Current Guidelines for Ventilation • CPR with Advanced Airway: 8 – 10 breaths/minute • Post-resuscitation: 10 – 12/min
    42. 42. 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
    43. 43. Reality Sucks… • Compression: Ventilation Ratio 2:1 • 47-48 Breaths a minute 47 Nails in a coffin!
    44. 44. Prolonged Ventilations • • • 􀂃 Ventilation Duration = 4.36 seconds / breath 􀂃 Ventilation Rate = 11 breaths / minute 􀂃 % time under Positive Pressure = 80%
    45. 45. Everyone sucks! • Milwaukee – Mean Ventilation Rate: – AFTER 2 months training: • Dallas • Tuscan • Chicago 37/minute 22/minute 30/minute 34/minute >30/minute
    46. 46. 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
    47. 47. Aware of importance of CPR? 1975 1978 1980s and 1990’s King County/Seattle Medic One EMS System Data, Cobb,
    48. 48. CPR FIRST? % ROSC
    49. 49. 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.
    50. 50. CPR IMPROVING DEFIB?
    51. 51. CPR Improving EPI?
    52. 52. WHERE DOES THE AIRWAY FIT IN?
    53. 53. • 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).
    54. 54. Intubate DURING CPR ! • Minimal / no interruption of compressions • More time (up to 2 minutes) to get the tube = better 1st pass success
    55. 55. Why not a supra/peri-glottis airway? • large study , 2005-2007, over 131K patients • Compared LMA, ETT, and EOA
    56. 56. 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.”
    57. 57. 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.”
    58. 58. 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).
    59. 59. 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).
    60. 60. 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.
    61. 61. 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.
    62. 62. 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.
    63. 63. CPR: Whats Next?
    64. 64. • 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.
    65. 65. Hands Only CPR??? • Single biggest change • “Hands Only CPR” AKA: Compression only CPR for lay persons and non HCP first responders.
    66. 66. KEY POINT: • HANDS ONLY CPR MAY IMPROVE ROSC BY 7% OVER TRADITIONAL CPR
    67. 67. New CPR Guidelines
    68. 68. Traditional Healthcare Version
    69. 69. 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.
    70. 70. 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.
    71. 71. Look, Listen, and Feel? • Confusion in Agonal Respirations vs. Good Respirations • “Look , Listen, and Feel” de- emphasized
    72. 72. ADJUNCTS IN CPR
    73. 73. CPR Prompts
    74. 74. CPR Feedback? CPR FEEDBACK?
    75. 75. 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.
    76. 76. 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).
    77. 77. 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).
    78. 78. • 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
    79. 79. 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).
    80. 80. 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
    81. 81. Therapeutic Hypothermia?
    82. 82. 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
    83. 83. 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
    84. 84. The Future??? • Increased focus on the “Metabolic Phase” • Cardiac ByPass • Mitochondrial medicine – Stabilizing the “Apotic Switch” • Ion Channel • Deep Hypothermia – Trauma Studies Ongoing
    85. 85. PIT CREW CPR
    86. 86. 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
    87. 87. 1 2 3 4 5 6
    88. 88. CPR 1 AIRWAY VENTILATION 1 2 3 CPR 2 /AED
    89. 89. 1 2 3 4 5 6
    90. 90. CPR 1 AIRWAY VENTILATION 2 BOSS 4 1 6 AIRWAY ASSISTANT 5 CPR 2 3 ACCESS MEDS MONITOR
    91. 91. PARAMEDICS: GIVE AWAY THE TUBE!!!
    92. 92. Checklist Medicine? • Derived from the Airline Industry • Oh Crap checklist, not step by step checkists
    93. 93. •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
    94. 94. “It is up to us to save the world.” - Peter Safar

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