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Historical Overview of CPR Guideline: G2005, G2010 then G2015

This presentation provides a detailed historical overview of the CPR guidelines from G2005 to G2015, with a focus on the major emphasis of G2005 and G2010. Topics covered include first response with AED, compression rate vs ROSC, impact of CPR factors on outcome, and more.

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Historical Overview of CPR Guideline: G2005, G2010 then G2015

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  1. Essentials for Anesthesiologists： “Historical Overview of CPR Guideline: G2005,G 2010 then G2015 “ Annual Meeting of Vietnam Society of Anesthesiologists 2016,June 23,24 @Quy Nhon, Vietnam Keiichi TADA MD, PhD Deputy Director & Board of Trustee Hamawaki Orthopaedic Hospital Hiroshima, Japan Board of Japan Resuscitation Council International Liaison Committee on Resuscitation

  2. Let’sTalkabout CPR

  3. By the way・・・・・・ What was the major emphasis of G2005 and G2010???

  4.                  First Response with AED %  100 75 50 0 AED return of spontaneous circulation(ROSC ) and AED 40 35 30 25 20 15 10 5 0  1975 1977 1979 1981 1983 1985 1987 1989 1991 19931999 Cobb, L. A. et al. JAMA 1999;281:1182-1188.

  5. 1.6 4.4 BLS 3.7 3.4 1.1 Impact of CPR factors for Oucome Variable Adjusted Odds Ratio Age < 75yrs First Link- Early Access Second Link- Bystander CPR Third Link- Early Defib Fourth Link- ACLS Stiell, I. G. et al. N Engl J Med 2004;351:647-656

  6. ROSC NR • Push hard and push fast 100 COMPRESSION, MIN-1 Compression Rate vs ROSC 80 60 40 20 QUARTILE Yu Circulation 2002;106:368

  7. CPR SYSTOLE (compression) CPR DIASTOLE (relaxation) Coronary Perfusion Pressure (Ao diastolic - RA diastolic)

  8. Essentials for Anesthesiologists： “Historical Overview of CPR Guideline: G2005,G 2010 then G2015 “ Annual Meeting of Vietnam Society of Anesthesiologists 2016,June 23,24 @Quy Nhon, Vietnam Keiichi TADA MD, PhD Deputy Director & Board of Trustee Hamawaki Orthopaedic Hospital Hiroshima, Japan Board of Japan Resuscitation Council International Liaison Committee on Resuscitation

  9. Let’sTalkabout CPR

  10. By the way・・・・・・ What was the major emphasis of G2005 and G2010???

  11.                  First Response with AED %  100 75 50 0 AED return of spontaneous circulation(ROSC ) and AED 40 35 30 25 20 15 10 5 0  1975 1977 1979 1981 1983 1985 1987 1989 1991 19931999 Cobb, L. A. et al. JAMA 1999;281:1182-1188.

  12. 1.6 4.4 BLS 3.7 3.4 1.1 Impact of CPR factors for Oucome Variable Adjusted Odds Ratio Age < 75yrs First Link- Early Access Second Link- Bystander CPR Third Link- Early Defib Fourth Link- ACLS Stiell, I. G. et al. N Engl J Med 2004;351:647-656

  13. ROSC NR • Push hard and push fast 100 COMPRESSION, MIN-1 Compression Rate vs ROSC 80 60 40 20 QUARTILE Yu Circulation 2002;106:368

  14. CPR SYSTOLE (compression) CPR DIASTOLE (relaxation) Coronary Perfusion Pressure (Ao diastolic - RA diastolic)

  15. G2005:Critical Concepts for Good CPR １）　Push hard , push fast: 100/min ２）　Allow full recoil after each compression ３）　Minimize interruptions in chest compression ４）　Avoid Hyperventilation

  16. Am J Med Vol.119, 2006.

  17. “Cardiocerebral Resuscitation improves Survival of Patients with Out-of-Hospital Cardiac Arrest”Michael J. Kellum et. al.: The American Journal of Medicine, 2006,vol119.p.335-340 200 uninterrupted chest compression Single shock No post shock rhythm and pulse check • Result: • Preceding 3 years: 92 shockable VF patients • 18(20%) survived, 14(15%) CNS Intact • 2) New Protocol Group: 33 shockable VF patients • 19(57%) survived, 16(48%) CNS Intact 200 uninterrupted chest compression ** initial airway management was limited to an oral pharyngeal device and supplemental oxygen

  18. Chest compression only CPR Am J Med Vol.119, 2006.

  19. ScientificKnowledgeGapsNadkarmietal. Circulation2007,116 Since 2005G・・・・・・・・ ①　Medical emergency team rapidresponseteamsincrease outcome of adult& pediatric CPA patients？？ ②　RecognitionofCardiacArrestanditscauses Recognition of Agonal respiration ??, Detection of cardiac arrest ?? Effectiveness of prone position??? Quick detection of cervical spine injury ？？ ③　Bodyposition What is optimal position of patients during and post CPR ④　DC Shock: Optimal shock energy ?? Optimal shock interval ?? Long-term after-effect of DC shock for cardiac function ⑤　BloodFlowGeneration compression-onlyCPR,effectiveness？？　 Effectiveness and safety of Autopulse & AirwayImpedanceThresholdDevice ⑥　AirwayManagement・・・・・・・Best artificial AIRWAY ⑦　Compression & Respiration Optimal compression vs Respiration ratio??For child?? For neonate??？？　　 ⑧　Oxygenation How to give optimal oxygen in BLS ⑨　Drug: ⑩　Post CPR treatment Effectiveness of ECPR?? Optimal blood sugar level in and after CPR？？

  20. 低体温のレベル　-°C 36-37=平常体温 36.5 = 血管収縮 33-36=軽度低体温 Therapeutic Hypothermia After Cardiac Arrest 34-35.5 = シバリング < 34.0 = NO SHIVERING! 26-32=中等度低体温 13-25=重度低体温 12>超低体温

  21. G2015 !!!

  22. VF Cardiac Arrest Survival Seattle & King County, 2002-2013 72% of witnessed arrests receive bystander CPR EMS personnel achieve median ≥ 80% CCFraction Slide created and used with permission of Dr. Thomas Rea, Seattle, Washington.

  23. New AHA Adult Chains of Survival IN-HOSPITAL (note new Surveillance and Prevention link) OUT-OF-HOSPITAL, Including EMS

  24. Social Media to Summon Rescuers? Recommendation: • It may be reasonable to incorporate social media technologies to summon rescuers in close proximity to a victim. Why? • Low evidence, but low risk with potential benefit Screen shot: San Ramon Fire Department website: http://mobile.firedepartment.org/?rev=0?reload

  25. COMPRESSION RATE AND SURVIVAL TO DISCHARGE (Idriss et al, Resuscitation Outcomes Consortium data, Circulation, 2012) • Observational study December, 2005-May, 2007 • Sharp decline in survival with average rate >140/min • Rate of 100-120/min reasonable Optimal rate (“sweet spot”?) Adjusted cubic spline depicting the relationship between average chest compression rates and probability of survival to hospital discharge

  26. Rapid Compression Rate can Compromise Depth Height of dark grey column indicates percent of compressions less than 3.8 cm rises substantially when compression rate 140/min or higher. Idris et al, Critical Care Medicine, 2015:43 (4): 840

  27. Chest Compression Rate: Updated Recommendation: • Compression rate: 100-120/minute (2010:at least 100/min). Why? • Absolute number of compressions delivered/minute linked with survival. • Actual compression rate often well below 100/minute. • Rates below 100/min or above 120/min adversely affect outcomes.

  28. Adult Chest Compression Depth: Updated Recommendation: • Compress at least 2 inches (5cm) for average adult • Avoid excessive compression depth ie, greater than 2.4 inches (6cm) Why? • Small study: more injuries with compressions greater than 2.4 inches (6cm).(Hellevuo et al, Resuscitation, 2013) Note: • Difficult to judge depth without devices • Rescuers typically don’t “push hard” enough

  29. Bystander Naloxone for Opioid Overdose: New Recommendation: In additional to standard BLS care, it may be reasonable for appropriately trained rescuers (lay or HCP) to give IM or IN naloxone for life-threatening emergency with suspected opioid overdose. Why? Naloxone may reverse opioid-associated respiratory depression. Note that standard resuscitation measures take priority.

  30. Delayed Ventilation by some ems providers Recommendation: • For witnessed OHCA with a shockable rhythm, EMS systems with priority-based multi-tiered response may use a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts. Why? • For victims with witnessed, sudden arrest and shockable rhythm, delaying PPV shown to be effective in these systems. • In studies cited, providers received additional training with emphasis on high-quality compressions.

  31. Ventilation During CPR with an Advanced Airway: Updated Recommendation: • May be reasonable to deliver 1 breath every 6 seconds (10 breaths/min) while continuous chest compressions are being performed (infants, children and adults). Why? • Simplified from range of 1 breath every 6-8 seconds (8-10 breaths/min). • Should be easier to learn, remember, and perform Note • Report of new study of ventilation during CPR tomorrow at ReSS

  32. Mechanical Chest Compression Devices Recommendation: • Manual chest compressions remain standard of care over mechanical chest compression devices. • Mechanical piston/compression devices may be a reasonable alternative to conventional CPR in specific settings (eg, where the delivery of manual compressions may be challenging or dangerous to the provider). Why? • Three large randomized trials comparing mechanical chest compression devices to conventional CPR demonstrated survival similar to that with conventional CPR. Such devices may enable continuation of high-quality chest compressions in a vehicle or during PCI, etc.

  33. Vasopressors in Cardiac Arrest Recommendations: • Vasopressin + epinephrine offers no advantage over standard dose epinephrine—vasopressin has been deleted from AHA ACLS Cardiac Arrest Algorithm. • It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest with initial nonshockablerhythm Why? • No benefit of vasopressin over epinephrine • Very large observational study found association of better outcome (increased ROSC, survival to hospital discharge, and neurologically intact survival) with earlier epinephrine for patients with non-shockable rhythms.

  34. LOW ETCO2 one element Predicting Failed Resucitation? Recommendation: • In intubated patients, failure to achieve an ETCO2 greater than 10 mm Hg by waveform capnography after 20 minutes of CPR may be considered one component of a multimodal approach to decide when to end resuscitative efforts, but it should not be used in isolation • Efforts should be made to optimize CPR quality Why? • Failure to achieve an ETCO2 greater than 10 mm Hg after 20 minutes has been associated with poor outcome in case series • Low ETCO2 likely indicates very low cardiac output and pulmonary blood flow during CPR

  35. Targeted temperature management (TTM) • TTM recommended for all patients who remain comatose following ROSC from cardiac arrest • TTM: select, maintain (for at least 24 hours) constant temperature between 32°C and 36°C • If patient still comatose: continue TTM beyond 24 hours by actively preventing fever. • Routine prehospital cooling of patients with rapid infusion of cold IV fluids is not recommended (no benefit, possible complications)

  36. Key TOPICS • Naloxone administration in combination with BLS care for opioid-associated life-threatening emergencies • Intravenous lipid emulsion considered for treatment of local anesthetic systemic toxicity • Refined recommendations regarding uterine displacement for CPR during pregnancy

  37. Pediatric Resuscitation • Reaffirmed C-A-B sequence • Reaffirmed that compressions + ventilation needed for most pediatric arrest (unless sudden, witnessed collapse) • Rescuers unwilling or unable to deliver breaths should perform compressions • Updated 1-rescuer and multi-rescuer algorithms

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