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What is the ideal chest compression:ventilation ratio?

What is the ideal chest compression:ventilation ratio?. Ventilation : Perfusion Match Good CPR ~1/4 - 1/3 of normal cardiac output alveolar ventilation ~1/4 - 1/3 of normal Additional breaths “dead space” ventilation Increase IT pressure. CPR ratios. Mathematical model

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What is the ideal chest compression:ventilation ratio?

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  1. What is the ideal chest compression:ventilation ratio? Ventilation : Perfusion Match • Good CPR ~1/4 - 1/3 of normal cardiac output • alveolar ventilation ~1/4 - 1/3 of normal • Additional breaths • “dead space” ventilation • Increase IT pressure

  2. CPR ratios Mathematical model Lay rescuers - adult victims 50:2 “best” Babbs, Resuscitation 2004;61

  3. Guidelines 2005- Ventilation • Compression/Ventilation Ration 30:2 • Deliver each rescue breath over 1 second • Give enough volume to produce visible chest rise • Avoid rapid and forceful breaths • Advanced Airway- give 1 breath every 6-8 seconds 1

  4. G U I D E L I N E S 2 0 0 5 • Emphasis  effective chest compression defibrillation • Chest Compressions OnlyContinuous chest compression (CCPR) • Shock First or CPR First

  5. Survival From Simulated CPR 80 70% 73% 24 hr CNS NORM 40 7% 0 CC Only IDEAL CPR NO CPR Ewy et al: Circulation 2005;111:2134-42

  6. Probability of Survival to Hospital Discharge Wik, L. et al. JAMA 2003;289:1389-1395.

  7. Defibrillation or CPR First % survival Wik, JAMA 2004

  8. Electrical Phase MINIMAL ISCHEMIA Hemodynamic Phase LOCAL ISCHEMIA RIGHT HEART V-P Metabolic Phase GLOBAL ISCHEMIA-INJURY Phases of VF Cardiac Arrest JAMA 2002;288:3035

  9. Electrical Phase EARLY DEFIBRILLATION CRITICAL DEFIBRILLATION 4MINS CHEST COMPRESSION HDE 4-10MINS HYPOTHEMRIA CONTROLLED REPERFUSION Hemodynamic Phase CORONARY-CEREBRAL PERFUSION PRESSURE CRITICAL Metabolic Phase NOVEL THERAPIES NEEDED Phases of VF Cardiac Arrest JAMA 2002;288:3035

  10. Guidelines 2005- • CPRbeforeDefibrillation • Immediate defibrillation is the treatment of choice for VF of short duration • OOH unwitnessed (EMS) VF, may give period CPR before rhythm check 1

  11. G U I D E L I N E S 2 0 0 5 • Emphasis  effective chest compression defibrillation • Single or Stacked Shocks • Pulse Check • Rhythm Check

  12. G U I D E L I N E S 2 0 0 5 Major Recommendations Single shock Followed by immediate CPR

  13. 1st Shock delivered 22 seconds after pads placed

  14. RE-VF 25 seconds after the 1st shock (No Chest Compressions yet)

  15. 2nd Shock delivered 34 sec after re-VF (Still No Chest Compressions) CPR finally begun after 1 min 17 sec from 1st shock

  16. Monophasic vs Biphasic WaveformShock Efficacy VF No waveform consistently related to  ROSC or Hospital Discharge

  17. Defibrillation SuccessOut-of-Hospital Cardiac Arrest First Shock Results (N=21/61) • Remained in VF- 19% • Shocked into Non-VF 81% • Perfusing rhythm 0% @TIME RESUME CPR – 45 SECONDS Kern Circulation 2002

  18. Prompt CPR after AED ‘p’ <0.05 10/18 9/18 9/18 Percent 3/18 3/18 3/18 Kern

  19. Will CPR Do Harm Post-Shock • Most ‘post-shock” PEA is “pseudo-PEA” -some pressure generated (~10/5 or 20/10 mmHg) -undetectable as a palpable pulse (Aufderheide/Monday) • Chest Compressions during post-shock organized rhythms does not precipitate re-VF (Hess & White)

  20. Guidelines 2005- • CPRafter Defibrillation • Resume CPR immediately following shock (and while charging) • No pulse or rhythm check for 5 cycles CPR (@ 2 minutes) 1

  21. G U I D E L I N E S 2 0 0 5 ACLSMajor Recommendations •  Emphasis advanced airway • Recommendation Intraosseous access  Emphasis ET drug administration

  22. ACLS PRIORITIES2 MINUTE CYCLES- TEAM DYNAMICS

  23. ECC – New Course Emphasis • Team Dynamics and Leadership • Outcome is determined by success of team and not the individual

  24. G U I D E L I N E S 2 0 0 5 ACLSMajor Recommendations • Amiodarone – Lidocaine either • Epinephrine- Vasopressin ET discouraged • Atropine 0.5 mg - ACS

  25. G U I D E L I N E S 2 0 0 5 Summary ACLS • Emphasis on High-Quality CPR • Simplified Algorithms • Recommend expert consultation • Use IV / IO Access • limit ET administration • Limit, defer Advanced Airway Use • Especially endotracheal tube • Primary confirmation of ET- dual method

  26. Key studies- Amiodarone ARREST TRIAL Kudenchuck 1999 ALIVE TRIAL Dorian 2002 amiodarone 5 mg/kg vs. lidocaine 1.5 mg/kg)

  27. Vasopressin-Epinephrine Lindner 1997

  28. Vasopressin-Epinephrine Stiell 2001

  29. Vasopressin-Epinephrine Stiell 2001 Wenzel 2004

  30. Vasopressin-Epinephrine Wenzel 2004

  31. Lone HCP- Tailor Sequence Actions Check for Adequate Breathing Open airway in trauma patients Avoid Excessive Ventilation (too fast, too much) 1 breath Q 8-10secs 30:2 compression ventilation ratio Continuous CPR with advanced airway Rescuers rotate every two seconds Push hard, push fast, allow full chest recoil Pulse check >5  10 seconds G U I D E L I N E S 2 0 0 5 Summary BLS HCP

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