in hospital cardiac arrest

1. In-hospital Cardiac Arrest: First
and foremost,
Chest Compressions
Charles L Campbell MS MD
Associate Professor of Medicine
University of Kentucky College of
Medicine

2. • No Disclosures

3. Outline
• IHCA
• Hospitals Vary in Outcome
• Why
• What is recommended
• How should it be done
• Does it really matter

4. IHCA is pretty common…
• ˜200,000 in the US
• Survival is 18-20%
• There is tremendous
variability among
hospitals
• Get with the Guidelines
• 135,896
– 20% with Ventricular
fibrillation or Ventricular
tachycardia
– 64% occur in an ICU
• Median Survival Varies
– 8.3% at the lowest Decile
– 31.4 at the highest
JAHA. 2014;3:e000400

5. JAHA. 2014;3:e000400

6. Clinical Feature Odds Ratio P
VT/VF 3.14 <0.0001
PEA 1.06 0.002
Etiology
Toxicologic
2.36
ICU 1.60 <0.0001
Monitored 1.72 <0.0001
Comorbid Hepatic
insufficiency
0.54 <0.0001
Comorbid Cancer 0.50 <0.0001
Arrest time at
night
0.74 <0.0001
Arrest time
Weekend
0.86 <0.0001
JAHA. 2014;3:e000400

7. JAHA. 2014;3:e000400

8. What seems to work?
• Performing ACLS
correctly is associated
with an improvement in
outcome
• MUSC study
• Compared guideline
adherence for survivors
vs. non-survivors
– 75 survivors
– 75 non-survivors
• Survivors older and with
more cormorbidities
Resuscitation. 2013;85:82-87

9. Resuscitation. 2013;85:82-87

10. Resuscitation. 2013;85:82-87

11. Resuscitation. 2013;85:82-87

12. Resuscitation. 2013;85:82-87

13. • Each 10% improvement
in adherance results in
a ˜30% increase in
ROSC.
Resuscitation. 2013;85:82-87

14. What is Happening
• Weisfeldt and Becker
1. Electrical Phase
1. 4 min
2. Defibrillation alone
may be effective
2. Circulator Phase
1. Chest compressions are
necessary
3. Metabolic Phase
4. Stone Heart
JAMA.2002;288:3035-3038

15. Time course of VF

16. Circulation. 2005;111:1136-1140 and e294

17. J Cardiovascular Magnetic Resonance. 2011;13:17
Hypothermia during VT/VF

18. What is Recommended
• Defibrillation
• Chest Compressions
• Oxygenation
• Medications
• Procedures

19. NEJM 2008;358:9-17

20. Chest Compressions
• Place patient on a firm surface
– Backboard
– Deflation of air mattress
• Had in the middle of the chest
– 5 cm of depression
– Allow complete recoil
• Lifting the hand completely of the chest can improve
recoil
Circulation. 2010;122:S685-705

21. How Fast
• Rate 100-120 cpm
• Deliver >80 per minute
– That means minimal interruption
• Duty Cycle
– Time between the start of one compression and
the start of the next
– Target is 50%
– As much time relaxing as compressing
Circulation. 2010;122:S685-705

22. Circulation. 2005;428-434

23. Circulation. 2005;428-434

24. Circulation. 2005;428-434

25. Circulation. 2012;125:3004-12
• ROC consortium (9 sites)
• OHCA in which monitors/defib measured chest compression
rates
• 3098 cases analyzed

26. Circulation. 2012;125:3004-12

27. Circulation. 2012;125:3004-12
Compression rate vs Compressions
Delivered

28. Circulation Qual Outcomes.2013;6:148-156

29. Compression Depth

30. Resuscitation. 2005;64:363-372

31. Circulation Qual Outcomes.2013;6:148-156

32. Recoil Matters…

33. Resuscitation. 2006;71:341-351

34. Resuscitation. 2006;71:341-351

35. Resuscitation. 2006;64:353-362

36. Circulation Qual Outcomes.2013;6:148-156

37. Resuscitation, 2007;73:54-61

38. Resuscitation, 2007;73:54-61

39. Resuscitation, 2007;73:54-61

40. Resuscitation. 2009;80:743-751

41. Non-Shockable Rhythms

42. Circulation. 2012;125:1787-94

43. Circulation. 2012;125:1787-94

44. Chest Compressions and Defibrillation

45. Resuscitation. 2006;71:137-145

46. Resuscitation. 2006;71:137-145

47. • Survival from OHCA improved after the implementation of
a protocol that required 90 seconds of CPR prior to the
delivery of a shock via an AED
– 24% to 30%
– Particularly in those in whom the intial response interval was >
4 min.
JAMA. 1999;281:1182-1188

48. Resuscitation. 2008;77:10-15

49. Resuscitation. 2008;77:10-15

50. Resuscitation. 2008;77:10-15

51. Mechanical CPR?

54. Conclusions
• Chest Compressions are the cornerstone of
resuscitation
– Rate
– Depth
– Recoil
– Minimizing Interruptions
– Feedback is probably helpful
• In some cases chest compressions aid
defibrillation
• Mechanical chest compressors have not been
demonstrated to be helpful