This is a presentation given at the 2020 Grangeville EMTA Spring Fling

2. 1 Before we get started

3. Some thoughts to
start us off….
7 MANTRA’S OF QUALITY RESUSCITATION

4. #1: Measure, then
Improve, Then Measure
again…

5. CARES Registry should be state
wide

6. #2: “WHEN YOU HAVE SEEN ONE EMS SYSTEM, YOU
HAVE SEEN ONE EMS SYSTEM”

7. #3: It’s Not Complicated, But
It’s Not Easy

8. #4: Change Occurs Step by Step

9. #5: Performance,
Not Protocol

10. #7: Everyone in VF Survives

11. It Takes a System To Save a Victim

12. What is
Resuscitation?

13. What if I said
resuscitation is
Kung Fu?

14. Why I am doing this lecture….

15. A need for
change…
Approximately 350,000
persons die from out-of-
hospital cardiac arrest
each year in North
America.

16. CPR in Hollywood…
• ROSC: 75%
• discharged
neurologically
Intact: 67%

17. CPR in Real Life
ROSC between 0.1% and 49%
◦ 3-7% typical
◦ Outliers > 60% VF ROSC
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

18. EMS Perception: Nearly everyone dies….

19. But there
is hope…
HOWARD SNITZER, 59,
SURVIVED 96 MINUTES OF CPR
WITH NO NEURO DEFICITS.

20. Where we were…
2013
Adult 203 medical cardiac arrests.
◦ 145 suspected cardiac.
39% ROSC
◦ 50% ROSC with Bystander CPR
2015
Adult 224 medical cardiac arrests.
◦ 178 suspected cardiac.
50% ROSC (+11%)
◦ 60% ROSC with Bystander CPR
(+10%)

21. Where we are now…
2016
Adult 253 medical cardiac arrests.
◦ 204 suspected cardiac.
36.2% ROSC
◦ 45% ROSC with Bystander CPR
2017
Adult 190 medical cardiac arrests.
◦ 190 suspected cardiac.
44% ROSC
◦ 37.5% ROSC with Bystander CPR

22. 2017 vs 2018 CARES Data

23. National vs. ACCESS CARES data, 2018

24. Why does CPR
work?
SCIENCE BEHIND HIGH PERFORMANCE CPR

26. KEY
POINT:
CPR, NOT PARAMEDICS,
SAVE LIVES IN MOST
CARDIAC ARRESTS

27. Resuscitation
Arsenal
CPR
Defibrillation
Advanced Airways
IV’s and IO’s
Epinephrine
Antiarrhythmics
Sodium Bicarbonate
Other WIZ-BANG! Paramedic stuff

28. A Little More in Depth

30. How did we get
better?
INTRO TO HIGH PERFORMANCE CPR

31. What have you
heard about High
Performance or Pit
Crew CPR?

34. What are our metrics of performance?
RATE
◦ 100-120
◦ 110 ideal
DEPTH
◦ 2”
RELEASE/RECOIL
◦ Complete
UNINTERRUPTED
◦ 3 second goal
◦ 80% compression fraction
DECREASED VENTILATION
◦ 6-10/min
5 KEY
ASPECTS
OF
GOOD
CPR!

35. Key
ingredients to
our recipe
RATE
•Improving Perfusion through 220 continuous compressions
DEPTH
•Improving Performance with Feedback and peer
monitoring
RELEASE/RECOIL
•Improving Performance with Feedback and peer
monitoring
UNINTERRUPTED
•Reducing interruptions via assignments and positions
•Reducing interruptions via “Calling 200”
•Reducing interruptions via Hovering
•Reducing interruptions via pre-charging
DECREASED VENTILATION
•Decreasing ventilation rate/volume with Feedback and
peer monitoring
•Improving ventilations with 2 person methods

37. Compression…..
Increases intrathoracic pressure
Ejects Blood from the heart and lungs
“Good” compression increases cardiac
output (CO) and blood pressure
“Bad” Compressions hinders it
Tissue Perfusion
Remember, you are not just compressing the
heart, but the but the whole chest.

38. 5 sec
80
160
mmHg
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

39. 0
5 sec
80
160
mmHg
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

40. ROSC Associated with CPP

41. Compression Depth

42. 2 inches

43. Edelson DP et al., Resuscitation 2006;71;137-145

44. Complete Recoil

45. Blood Flow during CPR
10-20% OF NORMAL BLOOD FLOW TO THE
HEART
20-30% OF NORMAL BLOOD FLOW TO THE
BRAIN

46. 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

47. Poor Recoil = Increased Intrathoracic
Pressure

48. KEY POINT
Complete
Chest
Recoil is
essential
to survival

49. Uninterrupted Compression's

59. Poor Recoil = Increased Intrathoracic
Pressure
“The physiological penalty of assisted ventilation, with
its frequently incorrect rate and duration, is a persistently
positive intrathoracic pressure throughout the
decompression phase of CPR. This decreases cardiac
preload, cardiac output, and hinders right ventricular
function.”
- Bobrow BJ, Ewy GA. Ventilation during resuscitation efforts for out-of-hospital primary
cardiac arrest. Curr Opin Crit Care. 2009;15(3):228–233.

61. Ventilation control 6-10 times a minute.

62. Focus on Compressions not
Ventilation!!!

64. Zoll Dashboard Display
Rate indicator
Perfusion
performance
indicator
Depth indicator
Release
ETCO2
CPR Quality

65. Personal Feedback

66. Ada County’s High Performance Model of
CPR

67. Disclaimer!!!
There are many takes on High Performance CPR, this is just “ours” that
fits “our” system.
◦ It is not perfect
◦ It is not the only way
The science is always changing, follow the science, not the loudmouth
(me).

69. Positions for ACP/A.C.C.E.S.S. High
Performance CPR - BLS
COMPRESSIONS
 Position1/2 (alternating)
 Performs high-quality
compressions•:
 Hand placement on
lower half of sternum
 200 compressions @
110/minute
 Approximately 2 minutes
per cycle
 Complete recoil after each
compression
 Calls “180” and counts
down.
 Compresses at least 2
inches (5 cm)
 Complete Recoil
 “Hovers: when alternating
and during pauses
 Peri-shock pauses to
under 3 seconds.
AIRWAY
 Position 1/2
(alternating) ventilates at a
rate of 1 breath every 6-10
seconds (6-10/minute)
 Delivers breaths
asynchronously with
compressions with short
“upstroke” ventilations
 Position 3 establishes a
good 2 handed seal and:
 Maintains proper
head/airway position
including ear to sternal
notch
 Inserts adjunct as needed
based on scope of practice
without stopping
compressions.
 Visible chest rise with
each breath
TEAM LEADER/Code Commander
Every resuscitation must have a team leader
 Assigns roles PTA ,  Makes treatment decisions  Monitors performance
 Assumes responsibility for roles not assigned.  Communicates status on radio and
in person
 Should be highest certification.  Often airway position (3).

70. Positions for ACP/A.C.C.E.S.S. High
Performance CPR – BLS + ALS Intergration
COMPRESSIONS
 Position1/2 (alternating)
 Performs high-quality
compressions•:
 Hand placement on
lower half of sternum
 200 compressions @
110/minute
 Approximately 2 minutes
per cycle
 Complete recoil after each
compression
 Calls “180” and counts
down.
 Compresses at least 2
inches (5 cm)
 Complete Recoil
 “Hovers: when alternating
and during pauses
 Peri-shock pauses to
under 3 seconds.
AIRWAY
 Position 1/2
(alternating) ventilates at a
rate of 1 breath every 6-10
seconds (6-10/minute)
 Delivers breaths
asynchronously with
compressions with short
“upstroke” ventilations
 Position 3 establishes a
good 2 handed seal and:
 Maintains proper
head/airway position
including ear to sternal
notch
 Inserts adjunct as needed
based on scope of practice
without stopping
compressions.
 Visible chest rise with
each breath
Intervention Medic
 IO/IV Access Administer Medications  May run manual defibrilator
Communicates with team
ALL INTERVENTIONS SECONDARY TO BLS TEAM
EFFORTS
TEAM LEADER/Code Commander
Every resuscitation must have a team leader
 Assigns roles PTA ,  Makes treatment decisions  Monitors performance
 Assumes responsibility for roles not assigned.  Communicates status on radio and
in person
 Should be highest certification.  Often Intervention Medic.

72. What about the Airway?

73. Who Cares??? (I do…)

75. “Out-of-hospital cardiac arrest outcomes with
“pit crew” resuscitation and scripted initiation
of mechanical CPR”
444 patients in the A-TCEMS system. ½ recived manual, ½ received
LUCAS.
“Conclusions: In this EMS system with a standardized, "pit crew"
approach to OHCA that prioritized initial high-quality initial resuscitative
efforts and scripted the sequence for initiating mechanical CPR, use of
mechanical CPR was associated with decreased ROSC and decreased
survival to discharge.”
“In the propensity matched analysis (n = 176 manual CPR; 176
mechanical CPR), both ROSC (38.6% vs. 28.4%; difference: 10.2%; CI:
0.4% to 20.0%) and survival to discharge (13.6% vs. 6.8%; difference:
6.8%; CI: 0.5% to 13.3%) remained significantly higher for patients
receiving manual CPR.”

76. Future of the Lucas?
After 10 minutes?
Transport Only?
Limited Resources?