HIGH QUALITY CPR: IS IT TIME FOR MECHANICAL ASSISTANCE?

Transcription

1 HIGH QUALITY CPR: IS IT TIME FOR MECHANICAL ASSISTANCE? EMERGENCY NURSES ASSOCIATION Nicole Kupchik MN, RN, CCNS, CCRN-K, PCCN-CMC

2 Objectives Discuss issues with CPR performance in hospitals Describe challenges to providing high quality CPR Discuss the data behind the use of mechanical CPR devices

3 Let s start with cardiac arrest basics In resuscitation, what matters?

4 In resuscitation, what matters? 2015 Guidelines overview Chest compression rate /min Depth inches Minimize peri-shock pauses Do NOT over-ventilate!!! Utilize Capnography for ET placement, CPR quality, ROSC Medications: Epinephrine 1 mg every 3 5 min Amiodarone 300 mg IV for ventricular fibrillation

5 Poor quality CPR should be considered a preventable harm Meany, Bobrow, Mancini et al (2013) Circulation 128(4):

6 Depth with fast CPR rates CC Rate 141

7 Minute by minute breakdown

8 CPR with a Backboard

9 Mattress Swing

10 Should we put an emphasis on intubation in the first 15 minutes? Andersen et al (2017) JAMA; 317:5 Favors NO intubation Favors intubation

11 60 minute case Minutes 1-26

12 When is CPR challenging? Prolonged codes Cardiac Cath Lab In a hospital bed When you don t have enough staff/limited resources On a morbidly obese patient Back of a moving ambulance Should we rethink the way we provide chest compressions?

13 Efficient Application

14 Manual CPR vs. Mechanical CPR 2589 patients 4 Swedish, 1 Dutch, 1 British EMS system LUCAS n = 1300 Manual CPR n = hour survival Follow up 6 months Rubertsson, Lingren, Smekal et al (2013) JAMA

15 LINC: Survival with good outcomes (CPC 1-2) 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% L-CPR (N=1300) M-CPR (N=1289) ICU discharge (CPC 1-2) Hospital discharge (CPC 1-2) At 1 month (CPC 1-2) At 6 months (CPC 1-2) 7.5% 8.3% 8.1% 8.5% 6.4% 7.8% 7.3% 7.6% L-CPR = LUCAS M-CPR = Manual Rubertsson et al, JAMA Jan 1;311(1):53-61

16 Does Mechanical CPR applied early make a difference? Seems to! RCT LUCAS 2 vs. manual CC LUCAS applied onsite vs. ambulance Excludes pulseless V-Tach MECCA Trial MEchanical Cardiopulmonary Resuscitation vs. Standard Manual CPR in OHCA by Emergency Ambulance Crew Anantharaman, Ng, Ang et al (2017) Singapore Med 58(7):424-31

17 Cath Lab Experience Retrospective analysis Cardiac Catheterization Lab 43 patients 12 Manual CPR, 31 Mechanical CPR ROSC 74% in MCC vs. 42% in Manual CPR Venturini et al Resuscitation; 115:56-60

18 Cardiac Cath Lab Survival with MCC Venturini et al Resuscitation; 115:56-60

19 In-Hospital MCC Meta-Analysis Couper et al Resuscitation;103: Observational & RCTs Low quality of evidence

20 Mechanical CPR with a Shock - #1

21 Pre-Shock Pause w/ Mechanical CPR-#2

22 mcpr & Capnography without, then with a Pulse Pulseless Capno 20 mm Hg with CPR Conversion to an organized rhythm Capno over 50 mm Hg

23 Can Mechanical CPR be used as a bridge?

24 The Paris experience 2013

25 Mechanical CPR as a bridge? The Art of E-CPR! Pre-hospital E-CPR in the Louvre Museum, Paris

26 ECMO Extracorporeal Membrane Oxygenation

27 56 year old with OHCA Transient ROSC 4 mg of Epi, but continues loss of pulse Unclear if STEs on ECG What to do next? Would anyone take this patient to the cath lab?

28 Mechanical CPR Devices

29 Case continued OHCA, RBBB Arrest in the Cath Lab

30 Stent placed to the LAD Arrest in the Cath Lab

31 ECMO comes to you?

32 2015 Feedback & Mechanical Devices Levels of Evidence ILCOR/AHA Recommendation Class LOE Using feedback devices to guide compression quality IIb B-R The use of mechanical compression devices may be a reasonable for use by properly trained personnel. The use of mechanical compression devices may be considered in specific settings where the delivery of high quality manual compressions may be challenging or dangerous to the provider. ECPR Venous/Arterial ECMO may be considered for refractory cardiac arrest when the cause is likely reversible IIb IIb C-EO C-LD Neumar et al (2015). Circulation;132[suppl 2]:S315-S367

33 Follow me! Nicole Kupchik Consulting & Nicole Kupchik Podcast: Resus10 (itunes & Stitcher)

34 In conclusion, HIGH quality CPR & early defibrillation matter! Manual CPR is extremely challenging in hospitals Mechanical CPR applied efficiently, can improve CPR quality