Updated lecture given to the 2018 Graingeville Spring Fling EMS Conference.

2. Special Thanks

3. Special Thanks
• Dr. Peter Safar
• Father of
Resuscitation
medicine
• Helped develop CPR
and much that
appears in this
presentation

4. Special Thanks

5. Resuscitation Academies

6. What is resuscitation?

7. What if I said
resuscitation is
Kung Fu?

8. Why I am doing this lecture….

9. CPR
History
• First discussed in 1958
• Kouwenhoven WB et al.
JAMA 1960;173:1064-7
• Reported that “anyone,
anywhere, can now initiate
cardiac resuscitative
procedures. All that is
needed is two hands.”

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

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

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. EMS Perception: Nearly everyone dies….

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

15. Where we are now…
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%)

16. So Let’s Talk a Little About CPR…

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

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

20. What CPR does…
10-20% of normal blood flow to the heart
20-30% of normal blood flow to the brain

21. Cardiac Output During CPR

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

27. 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!

28. Key ingredients to our recipe
• RATE
– Improving Perfusion through 200 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 180”
– 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

30. • 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.

31. 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

32. 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

33. ROSC Associated with CPP

34. COMPRESSION
DEPTH

35. 2 inches

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

37. COMPLETE RECOIL

38. 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

39. Poor Recoil = Increased Intrathoracic
Pressure

40. KEY POINT
Complete Chest
Recoil is
essential to
survival

41. UNINTERRUPTED
COMPRESSION'S

48. 0
20
40
60
80
100
≤10.3
(n=10)
10.5-13.9
(n=11)
14.4-30.4
(n=11)
≥33.2
(n=10)
Peri-shock pause, seconds
Shocksuccess,percent
90%
10%
55%
64%
p=0.003
Defibrillation success and pre-shock pauses
Edelson et al, 2006

52. 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.

54. 86%
13%
0%
20%
40%
60%
80%
100%
%survival
12 30
# ventilations per minute
p= 0.006
Aufderheide et al. Circulation 2004; 109:1960-5
Hyperventilation during CPR = Decrease in Survival

56. Minimal Better Ventilations

57. Focus on Compressions not
Ventilation!!!

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

60. CPR Feedback?Phillips CPR Feedback

63. Personal Feedback

64. ADA COUNTY’S HIGH PERFORMANCE MODEL OF CPR

65. 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).

67. 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).

68. 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.

70. What about the Airway?

71. Who Cares??? (I do…)