Aiming for high quality CPR: why it matters and how we can get there. Benjamin S. Abella, MD, MPhil, FACEP

Transcription

1 Aiming for high quality CPR: why it matters and how we can get there Benjamin S. Abella, MD, MPhil, FACEP Clinical Research Director Center for Resuscitation Science Department of Emergency Medicine University of Pennsylvania Laerdal SUN workshop Philadelphia, December 2014

2 Speaker disclosures Research Funding: Speaking Honoraria: NIH - NHLBI American Heart Association Medtronic Foundation Philips Healthcare Advisory Board: HeartSine Technologies CardioReady Volunteer: American Heart Association Sudden Cardiac Arrest Association

3 Cardiac arrest Electrical recording of the heart rhythm: Cardiac Normal arrest rhythm: chaotic heart rhythm is moving means no blood blood flow (no(functional cardiac output) output ) In cardiac arrest, abrupt and total loss of cardiac output Uniformly fatal unless immediate treatment given (e.g. CPR)

4 Cardiac arrest epidemiology in the US 400,000 arrests / year 2 / 3 Out-of-hospital 1 / 3 In-hospital survival to hospital 1-5% discharge 10-20% Seattle: 10-20%!

5 Mortality from cardiac arrest arrest % Surviving CPR defibrillation ROSC Time hospital discharge

6 Development of chest compressions Drs. Knickerbocker, Kouwenhoven, and Jude Johns Hopkins, 1950s studied defibrillation and chest compressions in the laboratory

7 Approaching 50 years of modern CPR A B A. Peter Safar, 1950s B. Early symposium on CPR 1961

8 Cardiac arrest: fundamentals of therapy Chain of Survival Prompt Access Early ACLS Early Provider ACLS Manual CPR (American Defib Heart Care Association)

9 Chest compression alone CPR Dispatch-assisted CPR and AED use If someone calls 911 and doesn t know CPR or how to use an AED, the dispatcher can coach them on the spot Growing concept across the US Recent publication from the American Heart Association, endorsing the use of dispatch 911 CPR instructions: Is patient conscious? no Is patient breathing normally? Sample algorithm for dispatch recognition of cardiac arrest no START CPR; INSTRUCTIONS Lerner et al, Circulation 2012

10 Chest compression alone CPR Bystander contacted standard CPR (n=279) chest compression alone (n=241) 29/279 (10.4%) 35/241 (14.6%) Improvement due to:? less time to train? better CPR strategy p=0.18 Hallstrom et al, 2000

11 Chest compression alone CPR: revisited Bystander contacted standard CPR (n=960) chest compression alone (n=981) 11.5% 14.4% (OR 2.9) Survival to DC

12 Unrealistic to ventilate well? 1996 Ventilation was the biggest technical challenge for lay rescuers Mouth-to-mouth is HARD

13 Compression-only: training is easier 2012 Lay public feels more Confident with CC only More willing to share Information with others

14 Standard CPR vs CC alone Blood pressure Time = chest compression Berg et al, 2001

15 Standard CPR vs CC alone Blood pressure Time = chest compression Berg et al, 2001

16 No flow / compression fraction Survival to discharge, % comp fraction, % Christenson J et al, Circ 2009 poor survival with lowest compression fraction in OHCA

17 Chest compression depth CPP, mm Hg inches vs 1.5 inches Survival: 100% 15% CPR duration, min ICCM, 2005

18 Chest compression depth CCM 2012

19 CPR quality and survival 2013 Rate of may be best; too slow or too fast may yield worse outcomes

20 CPR quality and survival 2013 Deeper compressions Favors survival; no max Depth identified

21 CPR first may improve survival Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation 24% (155/639) 30% (142/478) p=0.04 Defib first - AHA 42 months 36 months CPR (90 sec) first, then defib Cobb et al, 1999

22 CPR first may improve survival: RCT probability of survival time from collapse, min CPR first Standard care p=0.006 Wik et al, 2003

23 CPR sensing and recording defibrillator Similar defibrillators now made by both Philips and Zoll

24 Actual arrest transcript: U of C, 2004 Arrest transcript ventilations rhythm check ECG ECG: v tach ECG: v fib shock given compressions

25 Chest compression rates Number of 30 sec segments n=1626 segments R>120 Chest compression rate (min-1) Abella et al, 2005

26 Chest compression rates by survival Number of 30 sec segments p=0.003 No ROSC ROSC Mean rate, no ROSC group 79 ± 18 * Mean rate, ROSC group 90 ± 17 * >120 Chest compression rate (min -1 ) Abella et al, 2005

27 CPR renaissance: measuring CPR Valenzuela et al, Circ 2005 Wik et al, JAMA 2005 Abella et al, JAMA 2005 Aufderheide et al,circ 2004

28 Hyperventilation during EMS resuscitation 16 seconds v v v v v v v v v v mean ventilation rate: 30 ± 3.2 first group: 37 ± 4 after retraining: 22 ± 3 Aufderheide et al, 2004

29 Chest compression pauses before shocks 4:55 5:00 5:05 5:10 Compressions ECG Pause before shock

30 Dose-effect of pre-shock pauses VF removed, percent % 10.3 (n=10) 64% (n=11) p= % (n=11) 10% 33.2 (n=10) Pre-shock pause, seconds Edelson et al, 2006

31 Possible model underlying these data

32 Current CPR quality: summary 1. Slow compression rates 2. Frequent and lengthy pauses 3. Shallow compressions 4. Hyperventilation

33 The problem with cardiac arrest

34 The military solution

35 Debriefing intervention l Code review investigation: All residents and students rotating through resuscitation team roles Debrief teams on their events Weekly min resuscitation debriefing/ teaching sessions

36 Impact of CPR feedback and debriefing Edelson et al, 2008

37 Impact of CPR feedback and debriefing Edelson et al, 2008

38 Impact of CPR feedback and debriefing EMS version of the Edelson 2008 study Performed using Zoll feedback defibrillators in Arizona

39 Impact of CPR feedback and debriefing

40 AHA statement on CPR quality 2013

41 Concept of report cards for resuscitation

42 CPR in the workplace Friday, June 13, 2008 Tim Russert, TV correspondent Known asymptomatic coronary dz Suffered AMI à cardiac arrest Attempted resuscitation (CPR and defibrillation) failed Unknown CPR quality or pre-shock pause time

43 CPR in the home Friday, June 25, 2009 Michael Jackson died at home Respiratory arrest from drug OD Attempted resuscitation (CPR and defibrillation) failed CPR performed in the bed questionable quality, pauses in performance?

44 Demonstration of CPR saving lives March 17, 2012 Fabrice Muamba had cardiac arrest while on UK football field Arrest duration was over 78 minutes Prolonged CPR and shocks Full neurologic recovery

45 Improving EMS care with CC only Bobrow et al, 2008 Interventions: 1. Significantly delay intubation compressions before first shock 3. Minimize pre and post shock pauses Tripled survival to hospital discharge (3.8% à 9.1%)

46 Guidelines update 2010 New directions in CPR: Hands-only CPR evidence suggests mouth-to-mouth may not be required, especially for bystander response New for 2010 guidelines: A B C Airway-Breathing-Circulation is now Circulation-Airway-Breathing

47 The key importance of CPR Reflected in the poor impact of ACLS meds: 2009 Randomized trial of epinephrine versus no epinephrine For EMS treated cardiac arrest à NO SURVIVAL BENEFIT!

48 Assessment during CPR is poor In 2010, few options available to obtain output from patients during resuscitation Treatment (input) Patient receiving care Effects (output)

49 Assessment during CPR is poor In 2010, few options available to obtain output from patients during resuscitation Treatment (input) antibiotics Patient receiving care Patient with pneumonia Effects (output) Temp curve wbc count

50 Progress in resuscitation inputs/outputs CPR quality emphasis 30:2 CPR Quality CPR introduced Pulse check Rhythm strip Pulse check Rhythm strip Time (years) Pulse check Rhythm strip

51 Problem with CPR quality recording CPR recording gives incorrect output: measures provider, not patient medication log sheet antibiotics Patient with pneumonia Temp curve wbc count

52 Candidate patient-based outputs Need methods to measure physiology Physiologic measurement Example Coronary perfusion pressure Paradis NA, 1990 Arterial pressure Rivers EP, 1993 Cerebral oximetry Newman DH, 2004 Blood markers Adrie C, 2002 End-tidal CO 2 Ornato, 1989

53 End-tidal carbon dioxide (ET-CO 2 ) Advantages: non-invasive clinically available extensively studied CO 2 ET-CO 2 expiration inspiration

54 Does ET-CO 2 correlate with CPR quality? Sheak et al, AHA abstract presentation 2013

55 Key take home points 1.Cardiac arrest is not hopeless! 2.CPR quality has big impact 3.Minimize ventilations 4.Maximize chest compression rate and depth 5.Consider CPR feedback tools and code debriefing

56 Acknowledgements Lance Becker Marion Leary Bob Neumar Dave Gaieski Roger Band Brendan Carr Barry Fuchs Dan Kolansky Vinay Nadkarni Raina Merchant Kelsey Sheak Marisa Cinousis Emily Esposito Raghu Seethela