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Importance of CPR

Importance of CPR. Robert S. Cole. Credit where Credit is Due. Adapted from presentation by Ahamed Idris, MD, Professor of Emergency Medicine University of Texas Southwestern Medical Center at Dallas. Special Thanks. Dr. Peter Safar Father of Resuscitation medicine Helped develop CPR

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Importance of CPR

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  1. Importance of CPR Robert S. Cole

  2. Credit where Credit is Due • Adapted from presentation by Ahamed Idris, MD, • Professor of Emergency Medicine University of Texas Southwestern Medical Center at Dallas

  3. Special Thanks • Dr. Peter Safar • Father of Resuscitation medicine • Helped develop CPR • Directly responsible for the research used in therapeutic hypothermia.

  4. Objectives • Importance of maximizing CPR. • Why compression:ventilation ratio 30:2 ? • Complete chest wall recoil • Danger of hyperventilation • CPR First vs shock first • 1 shock vs 3 shocks • Minimize delay to shock • Impedance Threshold Device (ITD): Science

  5. A need for change… • Approximately 350,000 persons die from out-of-hospital cardiac arrest each year in North America. • Survival rate is poor among these patients, and most do not survive to hospital discharge. • New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought. • Other research suggests that an impedance threshold device (ITD) may improve outcome.

  6. CPR in Hollywood… • ROSC (Getting a pulse back) 75% • discharged neurologically Intact 67%

  7. 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

  8. Today: Nearly everyone dies….

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

  10. Importance Of CPR 10-20% of normal blood flow to the heart 20-30% of normal blood flow to the brain

  11. 3 Phase Model

  12. Cardiac Output During CPR

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

  14. Understanding Coronary Perfusion Pressure Note this is Aortic Pressure. CPP is “roughly” half Aortic Pressure.

  15. 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

  16. ROSC Associated with CPP

  17. Benefit of Continuous Chest Compressions

  18. Intra-thoracic Pressure and CPR?

  19. New Cardiac Guidelines (2005) • Rate of 100/minute. • Depth of 1 1/2–2 inches • (or more in larger people). • Complete chest recoil after each compression. • Ventilation (less is more). • No more than 10 ventilations per minute. • Inspiration phase of no more than 1 second • Minimize interruptions in chest compressions. • Rotate compressors every 2–3 minutes to minimize fatigue.

  20. 2005 to 2010 changes…

  21. Who does good CPR?

  22. Answer: NO ONE! Studies showed… • Chest compressions were not delivered about half of the time (too much “hands off”). • Most compressions were not deep enough. Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005

  23. Answer: NO ONE! Studies showed… Chest compressions were not delivered about half of the time (too much “hands off”). Most compressions were not deep enough. Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005

  24. Compression DEPTH • Target = 38-51 mm with complete release • Reality = only 27% achieve target Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005

  25. No-Flow Ratio (Interruption of CPR) • Target = less than 20% • Reality = 48% Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005

  26. Compression Rate • Target = ~100/min with complete release • Reality = 60/min due to “No Flow Ratio” Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005

  27. Compression Rate… Percent segments within 10 cpm of AHA Guidelines 31 % 36.9% Abella, et al 2005 Circulation

  28. Compression Rate…

  29. Barriers to staying on the chest… • Pausing for procedures • intubation, IV, pulse check, etc.). • Pausing for rhythm analysis. • Pausing after shock to await post-shock rhythm. • Pausing to charge, clear, and shock. • Unaware of importance of CPR in “big picture”

  30. Importance of complete recoil

  31. Get EVERY Compression Right Critical pressure for ROSC (Paradis et al. JAMA 1990;263:3257-8) Abella, et al 2005 Circulation

  32. Cerebral Perfusion Pressures and CPR Abella, et al 2005 Circulation

  33. Current Guidelines for Ventilation • CPR with Advanced Airway: 8 – 10 breaths/minute • Post-resuscitation: 10 – 12/min

  34. Compression-Ventilation Ratio • Ventilation rate = 12/min • Compression rate = 78/min. • Large amplitude waves = ventilations. • Small amplitude waves = compressions. • Each strip records 16 seconds of time

  35. Reality Sucks… • Compression: Ventilation Ratio 2:1 • 47-48 Breaths a minute 47 Nails in a coffin!

  36. Prolonged Ventilations • 􀂃Ventilation Duration = 4.36 seconds / breath • 􀂃Ventilation Rate = 11 breaths / minute • 􀂃% time under Positive Pressure = 80%

  37. Everyone sucks! • Milwaukee • Mean Ventilation Rate: 37/minute • AFTER 2 months training: 22/minute • Dallas 30/minute • Tuscan 34/minute • Chicago >30/minute

  38. Effect of Vent. Rate on CPP 12 RR /minute CPP 23.4 ± 1.0mmHg MIP 7.1 ± 0.7 mmHg/min 20 RR /minute CPP 19.5 ± 1.8 mmHg MIP 11.6 ± 0.7 mmHg/min 30 RR /minute CPP 16.9 ± 1.8 mmHg MIP 17.5 ± 1.0 mmHg/min

  39. Aware of importance of CPR? 1975 1978 1980s and 1990’s King County/Seattle Medic One EMS System Data, Cobb,

  40. CPR FIRST? % ROSC

  41. CPR FIRST BEFORE DEFIB? • The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation, especially in patients with delayed initial response intervals (longer than 4 minutes): 27 percent with CPR versus 17 percent without CPR. The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent. Cobb LA et al. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.JAMA 1999 Apr 7 281 1182-1188.

  42. CPR IMPROVING DEFIB?

  43. CPR: Whats Next?

  44. 90% of all changes to 2010 ECC are right in the BLS segment. Builds on and further enhances the changes and research discussed in the 2005 guidelines. COMPRESSIONS are the single most emphasized segment of resuscitation.

  45. Hands Only CPR??? Single biggest change “Hands Only CPR” AKA: Compression only CPR for lay persons and non HCP first responders.

  46. KEY POINT: • HANDS ONLY CPR MAY IMPROVE ROSC BY 7% OVER TRADITIONAL CPR

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