Importance of cpr 2010


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This is a slightly updated version of a previous lecture on the science behind CPR. I have deleted the older version to avoid confusion, though they are both essentially the same
This lecture is good for first responders of all levels (from lifegaurds to paramedics) to really bring home the importance of CPR. It has been my experiance that current CPR classess are lacking in this regard, therefore compliance with new CPR standards is lacking, and this promotes LAZY CPR. This is my attempt to remedy that issue.

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  • I want you to feel like a skinny white guy after a rocky movie….Ready to do anything!
  • Successful resuscitation following cardiac arrest requires an integrated set of coordinated actions represented by the links in the Chain of Survival (see Figure 1). The links include the following: ● Immediate recognition of cardiac arrest and activation of the emergency response system ● Early CPR with an emphasis on chest compressions ● Rapid defibrillation ● Effective advanced life support ● Integrated post– cardiac arrest care Emergency systems that can effectively implement these links can achieve witnessed VF cardiac arrest survival of almost 50%.11–14 In most emergency systems, however, survival is lower, indicating that there is an opportunity for improvement by carefully examining the links and strengthening those that are weak.3 The individual links are interdependent, and the success of each link is dependent on the effectiveness of those that precede it. Rescuers have a wide variety of training, experience, and skills. The cardiac arrest victim’s status and response to CPR maneuvers, as well as the settings in which the arrests occur, can also be heterogeneous. The challenge is how to encourage early, effective CPR for as many victims as possible, taking
  • When Howard Snitzer clutched his chest and crumpled on a freezing sidewalk outside Don's Foods in Goodhue, Minn., he was wearing gym shorts, fresh from his daily workout. Across the street, at Roy and Al's Auto Service, the Lodermeier brothers were getting ready to close. A local high school teacher ran up. By Courtney Perry, for USA TODAY Heart attack survivor Howard Snitzer looks at the group gathered around him at the Goodhue Fire Department. Enlarge By Courtney Perry, for USA TODAY Heart attack survivor Howard Snitzer looks at the group gathered around him at the Goodhue Fire Department. Ads by Google Goatee & Beard Styles The Gillette® Grooming Glossary. The Ultimate Resource For Grooming. Livable Cities Award Vote Win your place at the Philips Livable Cities Award ceremony. First Class Airfare For Less--Up to 60% Off International First Air-- Cook Travel "He said a guy had fallen on the sidewalk," Al Lodermeier says. At that moment, Don Shulte, owner of the grocery store, walked in. The three ran back to where Snitzer lay on the sidewalk. He wasn't breathing. He had no pulse. If he didn't get help soon, he would die. PHOTOS:  His rescuers never gave up For the next 96 minutes — more than an hour and a half — Al, his brother Roy, bystander Candace Koehn, who saw Snitzer fall, and more than two dozen other first responders took turns performing CPR on the fallen man. Their teamwork saved Snitzer's life, in what may be one of the longest, successful out-of-hospital resuscitations ever. What makes the incident even more striking was that it took place in rural Goodhue, pop. about 900, a town without a traffic light. "It's remarkable," says Bruce Wilkoff, a  Cleveland  Clinic heart rhythm specialist. "It's a great example of people doing the right thing and having it work out." Along with the Lodermeier brothers, both veteran first responders with more than three decades of experience on the volunteer Goodhue Fire Department, Snitzer's rescuers included police, volunteer fire fighters and rescue squads from the neighboring towns of Zumbrota and Red Wing. The  Mayo Clinic 's emergency helicopter, Mayo One, flew in from Rochester, Minn., almost 35 miles away. Their teamwork kept blood flowing to Snitzer's brain, making each rescuer a surrogate for his failing heart. "The brain survives, at best, five or six minutes when the blood flow stops," Wilkoff says. Nationwide, only about 5% of people who suffer cardiac arrest on the street are resuscitated and leave the hospital, he says. "I don't think the story's about me," says Snitzer, 54, who suffered his cardiac arrest on Jan. 5 and spent 10 days in the hospital. "It's about the guys in Goodhue and Mayo One." "The number one thing in this case was that someone recognized very quickly that (Snitzer) had arrested and began good, hard, fast CPR," says Mayo One paramedic Bruce Goodman, who arrived about 20 minutes after Snitzer's 5 p.m. collapse. Click here: 911 tape recording photo by Courtney Perry Click here to listen to a recording of the 911 tape that summoned first responders to Howard Snitzer's aid. During the course of the emergency, first responders shocked Snitzer a dozen times to jolt his heart out of its abnormal rhythm, or ventricular fibrillation. Ventricular fibrillation occurs when the heart's electrical circuits begin firing randomly, so the heart quivers and can't pump blood. Goodman and Mary Svoboda also gave Snitzer intravenous drugs to try to restore his heartbeat to normal. When he didn't respond, he called Mayo cardiac-arrest expert Roger White on his cellphone for guidance. Ultimately, they agreed to try a calculated overdose of a heart drug, amiodarone. It worked. "My end of this bargain is to honor the guys who did this for me," says Snitzer, who didn't know the details of his rescue for several days. When they met in his hospital room, Goodman says, he was stunned to see a man he didn't think would survive sitting up and talking with his brother. He asked Goodman: "Why didn't you stop?" It's a question, Goodman says, that he still doesn't have a good answer for. A new face in town Howard Snitzer, an unemployed chef, says he is a relative stranger in Goodhue. He moved there just a few months ago to live with his girlfriend Tammy Ryan, whose husband of 22 years died of a heart attack at home. His survival reflects a triumph over doubt as much as perseverence. The first responders who raced to Snitzer's assistance knew when they arrived that the odds were stacked against them — and him. "We've never had a case when we could save anybody, because we were never this close," says Roy Lodermeier. "This is the first case I know of, of someone who walks and talks and is getting around like (Snitzer) is." Even cities with the best records of responding to out-of-hospital cardiac arrests — places such as Seattle and Mayo's home city of Rochester — save fewer than half of all victims, about 45% at best, if the cardiac arrest is witnessed by a bystander, says Roger White, a leading expert in cardiac arrest and co-director of Mayo Clinic's emergency transport team, which includes Mayo One. Survivors sometimes suffer brain damage, White says, "a very compelling concern" in Snitzer's case. "If you'd told me that night that this guy was going to get up and walk out of the hospital," says Mayo One's Goodman, "I would probably have said, 'I'll bet my house against yours he won't.' " Location was vital Snitzer's first bit of good luck was that he dropped practically on Al and Roy Lodermeier's doorstep. Al began CPR while Roy Lodermeier detoured to the firehouse to get the rescue truck, with all of its emergency gear, before rushing to the grocery store. Another was the presence of Koehn, a CPR-trained corrections officer at the Goodhue County Adult Detention Center, who was in the store and watched him fall. She helped as Al Lodermeier dragged Snitzer inside and cut open his shirt with borrowed scissors. The two started performing CPR. "This is the first time I've ever had to do a rescue," she says. He was also lucky that the weather had cleared so Mayo One could respond to the call. "If he had collapsed earlier in the day, we might not have been able to get to him," Goodman says. When the helicopter landed at the firehouse, Goodman and Svoboda found Snitzer inside. He had been moved moments earlier by first responders who, as their numbers increased, found that they were running out of room in the grocery store. The rescuers hefted Snitzer, a 220-pound man, to a gurney and rolled him to an open bay at the fire hall. The Mayo One crew found a line of first responders taking turns pumping on Snitzer's chest. Al Lodermeier was at Snitzer's head, squeezing air into a mask over his mouth using a device called an ambu bag. "They were having trouble putting in an IV line to get drugs into him," Goodman says. "We put in a breathing tube." The airway turned out to be a key component of the decision-making to follow, because it measured carbon dioxide — a byproduct of breathing that revealed oxygen was reaching Snitzer's brain. Goodman and Svoboda began administering drugs: epinephrine, lidocaine, atropine and amiodarone, which they hoped would restore Snitzer's normal heart rhythm. It did not. Goodman called an emergency doctor at the Mayo Clinic, who told him that the rescue was probably futile. Goodman says he had his own doubts. Instead, he called White, who had helped to train him. He would call him four times. White said to keep going. "I must say, I was feeling increasingly desperate," White says, but the evidence that Snitzer was taking in oxygen and expelling carbon dioxide reassured him that Snitzer might make it. "We weren't at a point where we could give up yet." White suggested another dose of amiodarone, 150 milligrams more than is recommended for a second dose. Goodman had run out. He borrowed more from the Red Wing rescue crew. "Many things were going through my head at that point," he says. "This gentleman has not had a pulse for over an hour. He's unlikely to survive even if we can get a rhythm. Is this something we should call off?" He gave him the drug. Soon, he felt a pulse. White cleared him to load Snitzer on the helicopter and fly to Mayo's St. Mary's Hospital. But Goodman still thought Snitzer wouldn't survive, or he might wind up in a vegetative state. "I wasn't feeling we did a great thing," Goodman says. "More like, oh boy, what did we do?" 'Extremely grateful' Snitzer spent 10 days in the hospital. Doctors there cleared a blood clot from a critical artery and propped it open with a stent. The early reports on his condition were "pretty dismal," Goodman says. "When I came to work five or six days later, I looked him up to see when he had died. I found out he had a room number." Goodman and Svoboda went down to see him and told him for the first time what occurred. Snitzer says he's still sore from the CPR and weak from the heart attack. But he's extremely grateful to all the people who saved his life. "I'm a chef. I told them I'd be fattening them up every chance I get." On Tuesday, White flew to Goodhue to attend the monthly meeting of the Goodhue Fire Department and offer a seminar on the case. Snitzer and Ryan went too — and Snitzer met White for the first time. "I was floored," Snitzer says. "He hugged me for a long time. He wouldn't let go." For more information about  reprints & permissions , visit our FAQ's. To report corrections and clarifications, contact Standards Editor  Brent Jones . For publication consideration in the newspaper, send comments to  [email_address] . Include name, phone number, city and state for verification. To view our corrections, go to .
  • Early Access: Someone suspects or determines the victim is in sudden cardiac arrest and calls for help Early CPR: Someone trained in CPR keeps the victim’s blood flowing until defibrillation can begin Early Defibrillation: Someone trained in defibrillation shocks the victim as quickly as possible Early Advanced Care: Medical personnel provide advanced cardiac care which can include airway support, medications, and hospital services
  • Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation 2002;106:368-72.
  • Rescue Breaths A change in the 2010 AHA Guidelines for CPR and ECC is to recommend the initiation of compressions before ventilations. While no published human or animal evidence demonstrates that starting CPR with 30 compressions rather than 2 ventilations leads to improved outcomes, it is clear that blood flow depends on chest compressions. Therefore, delays in, and interruptions of, chest compressions should be minimized throughout the entire resuscitation. Moreover, chest compressions can be started almost immediately, while positioning the head, achieving a seal for mouth-to-mouth rescue breathing, and getting a bag-mask apparatus for rescue breathing all take time. Beginning CPR with 30 compressions rather than 2 ventilations leads to a shorter delay to first compression (Class IIb, LOE C).52–54 Once chest compressions have been started, a trained rescuer should deliver rescue breaths by mouth-to-mouth or bag-mask to provide oxygenation and ventilation, as follows: ● Deliver each rescue breath over 1 second (Class IIa, LOE C). ● Give a sufficient tidal volume to produce visible chest rise (Class IIa, LOE C).55 ● Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations.
  • These 2010 AHA Guidelines for CPR and ECC deemphasize checking for breathing. Professional as well as lay rescuers may be unable to accurately determine the presence or absence of adequate or normal breathing in unresponsive victims35,56 because the airway is not open57 or because the victim has occasional gasps, which can occur in the first minutes after SCA and may be confused with adequate breathing. Occasional gasps do not necessarily result in adequate ventilation. The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class I, LOE C). CPR training, both formal classroom training and “just in time” training such as that given through a dispatch center, should emphasize how to recognize occasional gasps and should instruct rescuers to provide CPR even when the unresponsive victim demonstrates occasional gasps (Class I, LOE B).
  • Importance of cpr 2010

    1. 1. Importance of CPR Robert S. Cole
    2. 2. Credit where Credit is Due <ul><li>Adapted from presentation by Ahamed Idris, MD, </li></ul><ul><ul><li>Professor of Emergency Medicine University of Texas Southwestern Medical Center at Dallas </li></ul></ul>
    3. 3. Special Thanks <ul><li>Dr. Peter Safar </li></ul><ul><li>Father of Resuscitation medicine </li></ul><ul><li>Helped develop CPR </li></ul><ul><li>Directly responsible for the research used in therapeutic hypothermia. </li></ul>
    4. 4. Objectives <ul><li>Importance of maximizing CPR. </li></ul><ul><li>Why compression:ventilation ratio 30:2 ? </li></ul><ul><li>Complete chest wall recoil </li></ul><ul><li>Danger of hyperventilation </li></ul><ul><li>CPR First vs shock first </li></ul><ul><li>1 shock vs 3 shocks </li></ul><ul><li>Minimize delay to shock </li></ul><ul><li>Impedance Threshold Device (ITD): Science </li></ul>
    5. 5. Why I am doing this lecture…. Why I am doing this lecture….
    6. 6. A need for change… <ul><li>Approximately 350,000 persons die from out-of-hospital cardiac arrest each year in North America. </li></ul><ul><li>Survival rate is poor among these patients, and most do not survive to hospital discharge. </li></ul><ul><li>New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought. </li></ul><ul><li>Other research suggests that an impedance threshold device (ITD) may improve outcome. </li></ul>
    7. 7. CPR in Hollywood… <ul><li>ROSC (Getting a pulse back) 75% </li></ul><ul><li>discharged neurologically Intact 67% </li></ul>
    8. 8. CPR in Real Life <ul><li>ROSC between 0.1% and 49% </li></ul><ul><ul><li>3-7% typical </li></ul></ul><ul><li>Survival to Hospital Admission: 23% </li></ul><ul><li>Survival to Discharge : 7.6% </li></ul><ul><ul><li>THIS HAS NOT IMPROVED SIGNIFICANTLY IN 30YEARS! </li></ul></ul><ul><li>Good Neurological Outcome: 0.1% and 30% </li></ul>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
    9. 9. Today: Nearly everyone dies….
    10. 10. But there is hope… Howard Snitzer, 59, survived 96 minutes of CPR with no neuro Deficits.
    11. 11. Importance Of CPR 10-20% of normal blood flow to the heart 20-30% of normal blood flow to the brain
    12. 12. 3 Phase Model
    13. 13. Cardiac Output During CPR
    14. 15. KEY POINT: CPR, not PARAMEDICS, save lives in most Cardiac Arrests
    15. 16. Understanding Coronary Perfusion Pressure Note this is Aortic Pressure. CPP is “roughly” half Aortic Pressure.
    16. 17. Understanding Chest Compressions <ul><li>Compression </li></ul><ul><li>Increased intrathoracic pressure </li></ul><ul><li>Compression of heart and lungs </li></ul><ul><li>Decompression (recoil) </li></ul><ul><li>Decreased intrathoracic pressure </li></ul><ul><li>Refilling of heart and lungs </li></ul>Complete chest recoil is critical
    17. 18. ROSC Associated with CPP
    18. 19. Benefit of Continuous Chest Compressions
    19. 20. Intra-thoracic Pressure and CPR?
    20. 21. New Cardiac Guidelines (2005) <ul><li>Rate of 100/minute. </li></ul><ul><li>Depth of 1 1/2–2 inches </li></ul><ul><ul><li>(or more in larger people). </li></ul></ul><ul><li>Complete chest recoil after each compression. </li></ul><ul><li>Ventilation (less is more). </li></ul><ul><ul><li>No more than 10 ventilations per minute. </li></ul></ul><ul><ul><li>Inspiration phase of no more than 1 second </li></ul></ul><ul><li>Minimize interruptions in chest compressions. </li></ul><ul><li>Rotate compressors every 2–3 minutes to minimize fatigue. </li></ul>
    21. 22. 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
    22. 23. Who does good CPR?
    23. 24. Answer: NO ONE! <ul><li>Studies showed… </li></ul><ul><li>Chest compressions were not delivered about half of the time (too much “hands off”). </li></ul><ul><li>Most compressions were not deep enough. </li></ul>Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005
    24. 25. Answer: NO ONE! <ul><li>Studies showed… </li></ul><ul><li>Chest compressions were not delivered about half of the time (too much “hands off”). </li></ul><ul><li>Most compressions were not deep enough. </li></ul>Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005
    25. 26. Compression DEPTH <ul><li>Target = 38-51 mm with complete release </li></ul><ul><li>Reality = only 27% achieve target </li></ul>Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005
    26. 27. No-Flow Ratio (Interruption of CPR) <ul><li>Target = less than 20% </li></ul><ul><li>Reality = 48% </li></ul>Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005
    27. 28. Compression Rate <ul><li>Target = ~100/min with complete release </li></ul><ul><li>Reality = 60/min due to “No Flow Ratio” </li></ul>Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005
    28. 29. Compression Rate… Percent segments within 10 cpm of AHA Guidelines 31 % 36.9% Abella, et al 2005 Circulation
    29. 30. Compression Rate…
    30. 31. Barriers to staying on the chest… <ul><li>Pausing for procedures </li></ul><ul><ul><li>intubation, IV, pulse check, etc.). </li></ul></ul><ul><li>Pausing for rhythm analysis. </li></ul><ul><li>Pausing after shock to await post-shock rhythm. </li></ul><ul><li>Pausing to charge, clear, and shock. </li></ul><ul><li>Unaware of importance of CPR in “big picture” </li></ul>
    31. 32. Importance of complete recoil
    32. 33. Get EVERY Compression Right Critical pressure for ROSC (Paradis et al. JAMA 1990;263:3257-8) Abella, et al 2005 Circulation
    33. 34. Cerebral Perfusion Pressures and CPR Abella, et al 2005 Circulation
    34. 35. Current Guidelines for Ventilation <ul><li>CPR with Advanced Airway: 8 – 10 breaths/minute </li></ul><ul><li>Post-resuscitation: 10 – 12/min </li></ul>
    35. 36. Compression-Ventilation Ratio <ul><li>Ventilation rate = 12/min </li></ul><ul><li>Compression rate = 78/min. </li></ul><ul><li>Large amplitude waves = ventilations. </li></ul><ul><li>Small amplitude waves = compressions. </li></ul><ul><li>Each strip records 16 seconds of time </li></ul>
    36. 37. Reality Sucks… <ul><li>Compression: Ventilation Ratio 2:1 </li></ul><ul><li>47-48 Breaths a minute </li></ul><ul><li>47 Nails in a coffin! </li></ul>
    37. 38. Prolonged Ventilations <ul><li>􀂃 Ventilation Duration = 4.36 seconds / breath </li></ul><ul><li>􀂃 Ventilation Rate = 11 breaths / minute </li></ul><ul><li>􀂃 % time under Positive Pressure = 80% </li></ul>
    38. 39. Everyone sucks! <ul><li>Milwaukee </li></ul><ul><ul><li>Mean Ventilation Rate: 37/minute </li></ul></ul><ul><ul><li>AFTER 2 months training: 22/minute </li></ul></ul><ul><li>Dallas 30/minute </li></ul><ul><li>Tuscan 34/minute </li></ul><ul><li>Chicago >30/minute </li></ul>
    39. 40. 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
    40. 41. Aware of importance of CPR? 1978 1975 1980s and 1990’s King County/Seattle Medic One EMS System Data, Cobb,
    41. 43. CPR FIRST? % ROSC
    42. 44. CPR FIRST BEFORE DEFIB? <ul><li>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. </li></ul><ul><li>Cobb LA et al. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.JAMA 1999 Apr 7 281 1182-1188. </li></ul>
    44. 48. CPR: Whats Next?
    45. 49. <ul><li>90% of all changes to 2010 ECC are right in the BLS segment. </li></ul><ul><li>Builds on and further enhances the changes and research discussed in the 2005 guidelines. </li></ul><ul><li>COMPRESSIONS are the single most emphasized segment of resuscitation. </li></ul>
    46. 50. Hands Only CPR??? <ul><li>Single biggest change </li></ul><ul><li>“Hands Only CPR” AKA: Compression only CPR for lay persons and non HCP first responders. </li></ul>
    48. 52. CAB??? <ul><li>Sequence change to chest compressions before rescue breaths (CAB rather than ABC) </li></ul><ul><li>This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds. </li></ul><ul><li>This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock. </li></ul>
    49. 53. Pulse Check? <ul><li>Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse. </li></ul><ul><li>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. </li></ul><ul><li>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 . </li></ul>
    50. 54. Look, Listen, and Feel? <ul><li>Confusion in Agonal Respirations vs. Good Respirations </li></ul><ul><li>“ Look , Listen, and Feel” de- emphasized </li></ul>
    51. 55. CPR Prompts
    52. 56. Therapeutic Hypothermia?
    53. 57. New CPR Guidelines
    54. 58. Traditional Healthcare Version
    55. 59. IMPORTANT POINT! <ul><li>RATE </li></ul><ul><li>DEPTH </li></ul><ul><li>RELEASE </li></ul><ul><li>UNINTERRUPTED </li></ul><ul><li>DECREASED VENTILATION </li></ul>5 KEY ASPECTS OF GOOD CPR!
    56. 60. “ It is up to us to save the world.” - Peter Safar