KACPR Symposium Guideline of Singapore CPR Lim Swee Han MBBS (NUS), FRCS Ed (A&E), FRCP (Edin), FAMS Senior Consultant, Department of Emergency Medicine, Singapore General Hospital Adjunct Associate Professor, Yong Loo Lin School of Medicine and Duke-NUS Graduate Medical School of National University of Singapore Treasurer and Member BLS Taskforce, ILCOR Immediate Past Chairman and Treasurer, Resusciation Council of Asia Secretary, Asian Society for Emergency Medicine President, Society of Emergency Medicine in Singapore
November 22, 1992 + 2006
(2005) Japan Resuscitation Council (2005) Korean Association of CPR (2005) National Resuscitation Council, Singapore (2005) National Resuscitation Council, Taiwan (2005) Philippine Heart Association (2010) The Heart Association of Thailand (2011) Resuscitation Council of Hong Kong (2016) Associate members Penang CPR Society (2014)
RCA Taskforce Members 1 to3 worksheet authors JRC 6, KACPR 2, NRCS 3, NRCT 3
BLS PICO (population, intervention, comparator, outcome) Questions PICO Question Type - Diagnostic: Dispatcher recognition of cardiac arrest Dispatcher instructions PICO Question Type Intervention: Resuscitation care for suspected opioid-associated emergencies Opioid overdose response education Drowning search and rescue EMS response interval High quality CPR Chest compression only CPR vs conventional CPR Chest compression depth Minimizing pauses in chest compressions
BLS Evidence Review Hand Placement Worksheet authors: Sungphil Chung, Ian R. Drennan, Swee Han Lim PICO: Among adults and children who are receiving chest compressions in any setting (P), does delivery of chest compressions on the lower half of the sternum (I), compared with any other location for chest compressions (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, cardiac output, harm (eg rib fracture), coronary perfusion pressure (O)? This review focused on studies reporting clinical or physiological outcomes related to hand position during chest compression. The remit differed from the COSTR 2010 review, 1 which also included CT, echocardiographic and manikin studies reporting on the anatomical structures that would be compressed with different hand positions and the efficiency of different instructional techniques for locating hand position. There were no studies reporting the critical survival outcomes. For the important outcome of physiological endpoints, one very low quality cross-over study in 17 adults with prolonged resuscitation from non-traumatic cardiac arrest observed improved peak arterial pressure during compression systole (114mmHg ± 51mmHg vs. 95mmHg ± 42mmhg) and end-tidal CO2 (11.0mmHg ± 6.7mmHg vs. 9.6mmHg ± 6.9mmHg) when compressions were performed in the lower third of the sternum compared to the centre of the chest, whereas arterial pressure during compression diastole, peak right atrial pressure and coronary perfusion pressure did not differ. 2 A second very low quality cross-over study in 30 adults observed no difference between end-tidal CO2 values and hand placement. 3 A further very low quality cross-over study in 10 children observed higher peak systolic pressure and higher mean arterial blood pressure when compressions were performed on the lower third of the sternum compared with the middle of the sternum. 4 We suggest therefore that chest compressions are performed on the lower third of the sternum (weak recommendation, low quality of evidence). This is based on limited, very low quality evidence, which shows improvement in some physiological end-points and the absence of studies reporting harm from this approach.
1. Sayre MR, Koster RW, Botha M, et al. Part 5: adult basic life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;122(16 Suppl 2):S298-324. 2. Cha KC, Kim HJ, Shin HJ, Kim H, Lee KH, Hwang SO. Hemodynamic effect of external chest compressions at the lower end of the sternum in cardiac arrest patients. The Journal of emergency medicine. Mar 2013;44(3):691-697. 3. Qvigstad E, Kramer-Johansen J, Tomte O, et al. Clinical pilot study of different hand positions during manual chest compressions monitored with capnography. Resuscitation. Sep 2013;84(9):1203-1207. 4. Orlowski JP. Optimum position for external cardiac compression in infants and young children. Annals of emergency medicine. Jun 1986;15(6):667-673.
2015 Consensus Timeline Grade Tables and Summary of Findings Posted Worksheets Posted International Consensus Conference Feb.3-7, 2015 Dallas Batch and Que old PICO Questions Continuous Evidence Evaluation Reviews 2011 2012 2013 2014 2015 2016 Dec. 2010 Porto Nov. 2011 Orlando Oct. 2012 Vienna April 2013 Melbourne Spring 2014 Canada Shorter Lock box icostr, Executive Summary & Guidelines Published on line Oct 2015
15 Oct 2015 Science
15 Oct 2015 Guidelines
Total population : 21,380,723
Idris AH Circulation. 2012;125:3004-12
Inclusion: Cardiac Arrest for whom electronic CPR compression depth data were available (Phillips, N=1869 and ZOLL, N=7246) Exclusion: Whose arrests were EMS witnessed Who received a shock from a bystander applied AED Who had more than 5 minutes of CPR before the pads were applied Whom at least one minute of electronic CPR compression depth data was not available Stiell IG et al. Circulation 2014
May 2007 to Dec 2010 Initial rhythms: VF/VT 23.9%, PEA 20.2%, Asystole 49.4% AED no shock,no strip 6.4% Cannot determine/missing 0.2% Outcomes: - ROSC 31.3%, - 1-day survival 22.8%, - Discharge 7.3% Stiell IG et al. Circulation 2014
Dallas 2015 Proposed Consensus on Science Statements For the critical outcome survival with good neurological outcome, we found very low quality evidence from two observational studies suggesting that a compression depth of more than 5 cm is better than any other compression depth. For the critical outcome survival to hospital discharge, we found moderate quality evidence from four observational studies suggesting that a compression depth of more than 5 cm is better than any other compression depth and that the optimal depth range is 4.5 to 5.5 cm. For the critical outcome ROSC, we found moderate quality evidence from eight observational studies suggesting that a compression depth of more than 5 cm is better than any other compression depth and that the optimal depth range is 4.5 to 5.5 cm.
Dallas 2015 Proposed Consensus on Science Statements Observational study 170 of 353 patients (183 excluded for incomplete data) Injuries were reported in 28%, 27%, and 49% with compression depths less than 5cm (2 inches), 5 to 6cm (2 to 2.4 inches), and more than 6cm (2.4 inches) respectively Treatment recommendation Chest compression depth of approximately 5cm (2 inches) (strong recommendation, low quality evidence) while avoiding greater than 6cm (2.4 inches) in an average adult (weak recommendation, low quality evidence) during manual CPR
Rescuer s weight vs CPR quality Female nurse in Japan Average body weight: only 53kg Hasegawa et al. J Physiol Anthropol 2014;33:16 19
Practiced chest compression till compress consistently 5cm rest 5min chest compression 5min Heavy weight 68.0 ±7.5kg Light weight 50.6 ±6.5kg Hasegawa et al. J Physiol Anthropol 2014;33:16
Inclusion: Cardiac Arrest for whom electronic CPR compression depth data were available (Phillips, Physio Control ZOLL, ) Exclusion: Whose arrests were EMS witnessed Who received a shock from a bystander applied AED Who had more than 5 minutes of CPR before the pads were applied Whom at least one minute of electronic CPR compression depth data was not available Idris et al. Crit Care Med 2014
Idris et al. Crit Care Med 2014
June 2007 to Nov 2009 Initial rhythms: VF/VT 24.2%, PEA 22.9%, Asystole 42.8% AED no shock,no strip 8.7% Cannot determine/missing 1.4% Outcomes: - ROSC 34.5%, - 1-day survival 18%, - Discharge 9.4% Idris et al. Crit Care Med 2014
Chest compression only CPR standard for the for lay-rescuers? Panic was cited as the major obstacle to laypersons performance of bystander CPR. The simpler Hands-Only technique may help overcome panic and hesitation to act
2010 American Heart Association Guidelines for CPR and ECC Because rescue breathing is an important component for successful resuscitation from pediatric arrests asphyxial cardiac arrests in both adults and children (eg. Drowning, drug overdose) and from prolonged cardiac arrests, conventional CPR with rescue breathing is recommended for all trained rescuers (both in hospital and out of hospital) Ogawa et al: BMJ 2011 Berg et al : Circulation 2010 Adult Basic Life Support S691
Chest compression only CPR Compression only CPR is instructed during dispatcher CPR Hüpfl M, Lancet 2010 Rescuers are unable or unwilling to provide mouth to mouth ventilations should be encouraged to perform good chest compressions
2005 Prospective, observational cohort Inclusion: Patients who experienced OHCA in Arizona between January 1, 2005, and December 31, 2009 Age 18 years OHCA of presumed cardiac origin not witnessed by EMS personnel Arrest was presumed to be of cardiac origin unless it was known to be caused by trauma, drowning, drug overdose, or asphyxia Exclusion: Obvious evidence of death Do-not-resuscitate-orders Bobrow BJ. JAMA 2010;304:1447-54
Bobrow BJ. JAMA 2010;304:1447-54
Compression only CPR Dissemination of compression only CPR in Japan Iwami T, et al. Circulation. 2015;132:415-422