The evidence behind ACLS: the importance of good BLS Benjamin S. Abella, MD, MPhil, FACEP CRS Center for Resuscitation Science Clinical Research Director Center for Resuscitation Science Vice Chair of Research Department of Emergency Medicine University of Pennsylvania Laerdal Workshop December 2014
Cardiac arrest is the ultimate EMS disease! arrest % Surviving CPR defibrillation ROSC Time hospital discharge
50 years of modern CPR A B A. Peter Safar, 1950s B. Early symposium on CPR 1961
Cardiac arrest: fundamentals of therapy Chain of Survival Prompt Access Early ACLS Early Provider ACLS Manual CPR (American Defib Heart Care Association)
Chest compression alone CPR Bystander contacted 9-1-1 2010 standard CPR (n=960) chest compression alone (n=981) 11.5% 14.4% (OR 2.9) Survival to DC
Standard CPR vs CC alone Blood pressure Time = chest compression Berg et al, 2001
Standard CPR vs CC alone Blood pressure Time = chest compression Berg et al, 2001
No flow / compression fraction Survival to discharge, % 0 10 20 30 0-20 21-40 41-60 61-80 81-100 comp fraction, % Christenson J et al, Circ 2009 poor survival with lowest compression fraction in OHCA
Chest compression depth CPP, mm Hg 40 32 24 16 8 2 inches vs 1.5 inches Survival: 100% 15% 0 1 2 3 CPR duration, min ICCM, 2005
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
CPR first may improve survival: RCT probability of survival 0.5 0.4 0.3 0.2 0.1 0 0 2 4 6 8 10 12 14 time from collapse, min CPR first Standard care p=0.006 Wik et al, 2003
CPR sensing and recording defibrillator Similar defibrillators now made by both Philips and Zoll
Using CPR feedback to improve quality Kramer Johansen, 2006 Abella, 2007
Actual arrest transcript: U of C, 2004 Arrest transcript ventilations rhythm check ECG ECG: v tach ECG: v fib shock given compressions
Chest compression rates Number of 30 sec segments 300 250 200 150 100 50 0 n=1626 segments 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 R>120 Chest compression rate (min-1) Abella et al, 2005
Chest compression rates by survival Number of 30 sec segments 210 180 150 120 90 60 30 p=0.003 No ROSC ROSC Mean rate, no ROSC group 79 ± 18 * Mean rate, ROSC group 90 ± 17 * 0 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 >120 Chest compression rate (min -1 ) Abella et al, 2005
CPR renaissance: measuring CPR Valenzuela et al, Circ 2005 Wik et al, JAMA 2005 Abella et al, JAMA 2005 Aufderheide et al,circ 2004
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
Chest compression pauses before shocks 4:55 5:00 5:05 5:10 Compressions ECG Pause before shock
Dose-effect of pre-shock pauses VF removed, percent 100 80 60 40 20 0 90% 10.3 (n=10) 64% 10.5-13.9 (n=11) p=0.003 55% 14.4-30.4 (n=11) 10% 33.2 (n=10) Pre-shock pause, seconds Edelson et al, 2006
Shock success by compression depth Shock success, percent 120% 100% 80% 60% 40% 20% 0% p=0.02 50% 62% 93% ACLS Range 100% n=10 n=13 n=14 n=5 <1 1-1.5 1.5-2 >2 Compression depth, inches Edelson et al, 2006
Improving EMS care with CC only Bobrow et al, 2008 Interventions: 1. Significantly delay intubation 2. 200 compressions before first shock 3. Minimize pre and post shock pauses Tripled survival to hospital discharge (3.8% à 9.1%)
Improving EMS care with CC only Confirmation of this finding: 2009
How to train for quality
Debriefing intervention l Code review investigation: All residents and students rotating through resuscitation team roles Debrief teams on their events Weekly 30-45 min resuscitation debriefing/ teaching sessions
Impact of CPR feedback and debriefing Edelson et al, 2008
Impact of CPR feedback and debriefing Edelson et al, 2008
Impact of CPR feedback and debriefing EMS version of the Edelson 2008 study Performed using Zoll feedback defibrillators in Arizona
Impact of CPR feedback and debriefing
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!
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 6.Use hypothermia after cardiac arrest
Questions??