CPR That Saves Lives
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This Talk is a Summary of: 1. Review the Importance of Quality in CPR 2. Discuss the Safety of “Hands-on” Defibrillation 3. Evaluate Manual vs Mechanical CPR
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CPR That Saves Lives
- 1. CPR That Saves Lives, Not Just ACLS for Dermatologists Salim R. Rezaie, MD Twitter: @srrezaie
- 2. Disclosures
- 3. Objectives
- 5. Cardio Cerebral Resuscitation (CCR) Ewy GA et al. Curr Opin Cardiol 2008
- 6. Evidence to Support CCR 0% 20% 40% 60% 80% 100% ROSC 24h Survival Neuro Intact 24h Survival 40.0% 26.7% 13.3% 86.7% 86.7% 80.0% ABC CPR CCC CPR 15 Pigs Per Arm
- 7. More Animal Studies Annals of EM 2002 Crit Care Med 2010 Resuscitation 2010 Compression only CPR IMPROVED 1. Coronary Perfusion Pressure 2. ROSC 3. 24 Hour Survival 4. Neuro Outcomes This is What We Care About
- 9. Human Studies Supporting CCR Ann Emerg Med 2008 0% 10% 20% 30% 40% 50% 60% 2001 2002 2003 2004 2005 2006 23% 23% 15% 58% 38% 44% 19% 23% 8% 48% 29% 38% Survivors Neuro Intact Survivors CCR CPR Standard CPR
- 10. Coronary Perfusion is Dependent on Active CPR Cunningham LM et al. American Journal of Emergency Medicine 2012
- 11. Inadequate Perfusion Pressure Cunningham LM et al. American Journal of Emergency Medicine 2012
- 12. CPR Pause Evaluation Pre-Shock Pause <10s Pre-Shock Pause >20s Peri-Shock Pause < 20s Peri-Shock Pause >40s Post-Shock Pause <10s Post-Shcok Pause >20s 35.1% 25.1% 32.6% 20.3% 31.8% 22.7% Survival Pre-Shock Peri-Shock Post-Shock* Circulation 2011*Not Statistically Significant
- 13. How Good Are We At CPR Rates 97 Arrests 813 Minutes of Resuscitation (CPR)
- 14. Suboptimal Compression Rate CPR Rate < 70 = 21.7% CPR Rate < 80 = 36.9% CPR Rate > 100 = 31.4%
- 17. Mechanical CPR Does Mechanical CPR Improve Neurologically Intact Outcomes?
- 18. “Hands-On” Defibrillation SAFE Circulation 2008 43 Simulated Shocks NO shocks perceived by rescuers
- 19. “Hands-On” Defibrillation NOT SAFE Resuscitation 2012 Vinyl Latex Nitrile Chloroprene Current Leakage Glove Breakdown Increased Defibrillation Voltage
- 20. Current Leakage and/or Breakdown of Gloves Within Output Range of Biphasic Defibrillator NONE 100% Safe
- 21. Safety of External Defibrillation Systematic Literature Review 29 Adverse Events – 15 During Regular Resuscitation Efforts Resuscitation 2009
- 23. Case Report of 1
- 24. www.rebelem.com
- 25. CPR During Defibrillator Charging 16 4 21 3 3 7 0 5 10 15 20 25 Pre-Shock Pause Post-Shock Pause Peri-Shock Pause Time(Seconds) Non-CDC CDC Sample size Not Large Enough For Clinical Outcomes Resuscitation 2014
- 26. “Hands-On” Defibrillation Bottom Line Does “Hands-On” Defibrillation Decrease Pre-Shock Pauses? Does “Hands-On” Defibrillation Improve Neuro Intact Survival Outcomes? Is “Hands-On” Defibrillation Safe? YES UNCLEAR UNCLEAR
- 27. Mechanical vs Manual CPR Load Distributing Band (LDB) Piston Driven (PD)
- 28. Why it Matters Mechanical Increase Rate Increase Depth Decreased Interruptions Should Equal Increased Survival Manual Decrease Rate Decrease Depth Increased Interruptions Should Equal Decreased Survival
- 29. Most Recent Meta-Analysis 12 Studies (8 LDB and 4 PD) 6,538 Patients Primary Outcome = ROSC Crit Care Med 2013
- 30. Results
- 31. Limitation Does ROSC = Increased Survival with Good Neurological Outcomes
- 32. Crap In = Crap Out
- 33. Best Quality Evidence PD vs Manual CPR LDB vs Manual CPR
- 34. LDB vs Manual CPR 28.5% 3.1% 29.5% 7.5% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% ROSC* Hosp D/C with CPC ≤ 2 LDB CPR Manual CPR Hallstrom et al JAMA 2006 *Not statistically significant
- 35. Limitation LDB CPR Group 80 Compression/min Manual CPR Group 100 Compression/min
- 36. LUCAS In Cardiac Arrest (LINC) Trial 23.6 7.5 8.5 23.7 6.4 7.6 0 5 10 15 20 25 4 Hr Survival* 1 Mo Survival w/ CPC ≤ 2* 6 Mo Survival w/ CPC ≤ 2* PD CPR Manual CPR LINC Trial JAMA 2014 *Not Statistically Significant
- 37. Time for Application of Device Time Without CPR Time to 1st Defibrillation Hallstom et al = 2.1 minutes longer until 1st defibrillation LINC Trial = 1.5 minutes longer until 1st defibrillation Not Recorded
- 39. Mechanical CPR Bottom Line 1. Does Mechanical CPR Improve Neurologically Intact Outcomes? NO
- 41. Clinical Bottom Line “Hands-On” Defibrillation – DECREASES CPR Interruptions – UNCLEAR Neuro Intact Survival – UNCLEAR Safety Mechanical CPR – DOES NOT Improve Neuro Intact Outcomes
Editor's Notes
- No Disclosures
- 1. Review the Importance of Quality in CPR 2. Discuss the Safety of “Hands-on” Defibrillation 3. Evaluate Manual vs Mechanical CPR
- Soap Box: People running code need to pay attention to the quality of CPR, don’t just go through the motions….
- CardioCerebral Resuscitation (CCR): Had its origins in Arizona and officially started using in 2003 Step 1: NRB (no intubation) Step 2: Continuous CPR (no pauses)
- Standard ABC CPR vs CCC CPR 15 pigs per arm CCC CPR had better ROSC, 24 hour survival, and 24 hour neurologically intact pigs What we care about when we review studies is neurological outcome…..not ROSC or survival…..who cares if a person survives but is brain dead
- Surrogates of neuro outcomes improved CPP, ROSC, 24hr survival….but the gold standard should be neuro outcomes
- CPC 2: Moderate disability but can perform activities of daily living So you may walk with a limp, but you can feed yourself, bathe yourself, and wipe your own ass!!!!
- 3 years of standard ABC CPR 3 years of CCR CPR in prehospital setting Significantly improved survival and neuro intact survivors
- Review article of CCR vs ABC standard CPR showed interruptions in CPR caused decrease coronary perfusion pressure
- More importantly the decrease in perfusion pressure is not just during the pause, but is also the time to build the pressure back up ischemic cardiomyocytes are less likely to be successfully defibrillated
- Pre-Shock Pause = Time Interval b/w CPR Cessation and Shock Delivery Post-Shock Pause = Time Interval Between Shock Deliver and CPR Resumption Peri-Shock Pause = Total Pre- and Post-Shock Pause Time Longer pre-shock pauses = less likely to survive
- Inpatient study: Almost 100 arrests (97 arrests) Just over 800 minutes of observed resuscitation and CPR (813 minutes)
- CPR Rates: CPR < 70 CPM 21.7% of the time = 1/4 CPR < 80 CPM 36.9% of the time = 1/3 CPR > 100 CPM 31.4% of the time = 1/3
- Hopefully I have proven to you that CPR matters….high quality, limited interruptions, appropriate rate all = better survival/neuro outcomes
- Is “Hands-On” Defibrillation Safe? Does “Hands-On” Defibirllation decrease Peri-shock pauses? Does “Hands-On” Defibrillation improve neuro intact outcomes?
- Does Mechanical CPR Improve Neuro Intact Outcomes?
- 43 Simulated Shocks No Shocks Perceived by Rescuers Bottom Line: “Hands-On” CPR with Biphasic External Defibrillation results in LOW levels of leakage current
- Dangerous: Some of all Single Glove Types and Some Double Glove Chloroprene Safety Uncertain: Some of all Single Glove Types and Some Double Glove Vinyl, Nitrile, and Latex
- 29 Adverse Events 7 Accidental/Intentional Defibrillator Misuse 3 Device Malfunction 4 During Training/Maintenance Procedures 15 During Reglar Resuscitation Efforts Mostly Tingling Sensation, Discomfort and Minor Burns No Long Term Effects Reported
- Cadaver Study 6 Cadavers defibrillated and rescuer received anywhere from 1 – 8 Joules of Electricity 1 Joule is the minimum dose of electricity to cause ventricular fibrillation
- I have heard Scott Weingart talk about being and advocate of “hands-on” defibrillation until he was shocked and couldn’t move his arm for several hours I realize that a single case report is not data, but this occurrence must be so rare that we have to pay attention to case reports in this case
- Shameless Plug: “Hands-On” Defibrillation not safe
- 129 OHCA cases CPR during defibrillator charging decreases pre-shock pauses study size not large enough for clinical outcomes But this decrease pre-shock pause should = better survival/neuro outcomes larger trials pending
- 12 Studies (8 Load Distributing Bands and 4 Piston Driven) Over 6500 patients Primary Outcome = ROSC Load Distributing Band Piston Driven
- Both Multicenter RCT with greater than 1000 patients
- LDB vs Manual CPR No diff in ROSC or neuro intact survival
- PD device vs Manual CPR No statistical diff in survival or neuro intact outcomes
- One Caveat: Long ambulance transport, there may be a place for this.