High Performance CPRSan Luis Obispo County EMS Agency

Thank you to our sponsors!!!

Emergency Medical Services Fund

WHY?• 400,000 cardiac arrests /year• 88 % occur out of the hospital > 911• National survival rate <8%• Survival of out-of hospital cardiac arrest

has remained stagnant• HPCRP programs – shockable rhythm

survival rate – 30-50%

What is Happening in SLO?(24 month review)

• 540 cardiac arrest responses• 424 received EMS treatment• 230 transported to a hospital• 71 had “shockable rhythm” on ALS arrival (16%)• 22 patients survived to discharge• SLO overall survival rate 5%• SLO survival rate of patients transported 10%

High Performance CPR (“Pit Crew CPR”)

• HPCPR Programs o Increase in out-of-hospital survival by 30-50%o Programs in Seattle and Arizona demonstrate out-of hospital

survival for witnessed “shockable rhythm” of 40-50%

• Goals for SLOo Increase overall survival rate through – public education, early

911, use of AED, and HPCPRo Increase the number of patients with shockable rhythm with

bystander CPR and HPCPRo Increase out of hospital survival for shockable rhythms that

meet the standards being seen in other HPCPR programs

Objectives for today

• History• Science• Elements of HPCPR

• CPR Rate/Depth/Recoil• Minimal Interruptions• Airway management

• Translating knowledge into practice• Hands-on practice• Simulation

• Review

HISTORY

1961A. Peter Safar, 1950s

B. Early symposium on CPR

A B

CPR is over 50 years old, but recent changes have shown increases in survival

Figure 2: Temporal Trends in OHCA Survival Over Time (Sasson et. al. Circuation: Cardiovascular Quality and Outcomes Nov. 2009.)

1960 >2010 What have we learned about CPR?

History has provide a better understanding of CPR

• CPR makes a difference! • CPR must be started as soon as a victim collapses• We must rely on a trained/willing public to initiate CPR • CPR performed, even by pros, it is often not done well• Compressions are interrupted too frequently• Excessive ventilation is provided too frequently• Chest compressions are often too slow and too shallow• CPR is a DYNAMIC process • CPR quality has a major impact on outcome

The Result > HPCR or PIT Crew Model

Same name…many versions

• CPR • Minimized interruptions ( < 5-10 sec.)• Effective compression (rate/depth)• Maximize compression fraction• Frequent rotation reducing

provider fatigue

• Controlled ventilations

• Defibrillation • Charge @ 200 compression

GOAL:MINIMIZE INTERRUPTIONS

Common “Tasks” > Interruptions

• Airway interventions and IVs• Ventilations• Pulse checks• Rhythm analysis• Defibrillation• Changing compressors• Patient movement

Interruptions - Old vs New

• Historical 30:2 • 100 compressions/min =18 sec. for compressions

• 5 sec. break for ventilations every 30 compressions• Results in active compression 78% of the time• NOT counting other breaks in CPR

• HPCPR/Pit Crew• Continuous compressions w/asynchronous ventilation• 10 sec break every 2 min = 92% compressions• 5 sec. break every 2 min = 96% compression

5 sec

80

160

mm

Hg

Time (sec)

40

120

0

Coronary Perfusion Pressures

Cerebral Perfusion Pressures

No Cerebral Perfusion

Single rescuer performing 30:2 with realistic 16 sec. interruption of chest compressions for MTM

ventilations

Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525

0

5 sec

80

160

mm

Hg

Time (sec)

40

120

Coronary Perfusion Pressures

Continuous Cerebral Perfusion Pressures

Single rescuer performing continuous chest compressions

Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525

Perfusion with continuous compressions

0

20

40

60

80

100

≤10.3(n=10)

10.5-13.9 (n=11)

14.4-30.4 (n=11)

≥33.2(n=10)

Pre-shock pause, seconds

Sh

ock

su

cces

s, p

erce

nt

90%

10%

55%64%

p=0.003

Defibrillation success and pre-shock pauses

Edelson et al, 2006

HPCPR Goal: Less than 5-10 second break

in every 2 minute cycle of CPR

GOAL:QUALITY CPRRATE/DEPTH/RECOIL

Rate Matters

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)

Nu

mb

er

of

30 s

ec

seg

men

ts300

250

200

150

100

50

0

n=1626 segments

Chest compression rates of auto pulse devices

Abella et al, 2005

DEPTH

40

32

24

16

8

0

1 2 3 CPR duration, min

CP

P, m

m H

g

ICCM, 2005

2 inches vs 1.5 inchesSurvival:

100%

15%

Survival better with compressions >2 inches deep

Sh

ock

su

cces

s, p

erce

nt

Compression depth, inches

n=10 n=5n=14n=13

p=0.02

Shock success by compression depth

Edelson et al, 2006

RECOIL ORCOMPRESSION FRACTION

How Does CPR Cause Blood Flow?Thoracic Pump

+

Ensure Total Chest Recoil with:

1) Lifting palm during compressionsor

2) Using feedback device

+

VENTILATIONS:SMALL AMOUNT ON UP STROKE

Breathing / Ventilation• Passive oxygen insufflation (POI)

• Ventilations may not be necessary during initial 4 cycles of CPR - consider utilization of nonrebreather at 15 L

• BVM - Small volume on upstroke of compression • (200-400cc every 10 compressions = 10-12/min)

• Remember: Ventilations still have important role in:• Pediatric arrests <15 y/o (15:2)• Secondary Cardiac Arrest (30:2)

• Trauma• Drowning• Hypoxic Cardiac Arrest• Suspected Respiratory Cause• Overdose, etc.

86%

13%

0%

20%

40%

60%

80%

100%

% survival

12 30

# ventilations per minute

p= 0.006

Aufderheide et al. Circulation 2004; 109:1960-5

Hyperventilation during CPR = Decrease in Survival

Hyperventilation >

• Excessive ventilation increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output and survival.

• Breaths that are too large or too forceful may cause gastric inflation and its resultant complications.

ETCO2 - capnography• Assess chest compression performance if ETCO2 is <10

mmHg during CPR. • An abrupt sustained increase to a normal value (35 to 40

mmHg) is an indicator of ROSC.• Sustained ETCO2 <10mmHG is useful in determining

termination.

Bringing Science to Practice

High-Functioning EMS CPR Teams

Starts with the Bystanders

35%

30%

25%

20%

15%

10%

5%

0%

17.7%

33.7%

Su

rviv

al to

Hosp

ital D

isch

arg

e

Std-CPR COCPR

Survival after Bystander CPR for OHCA in Arizona (2005 to 2010)Compression Only CPR (COCPR) Advocated and Taught

Bobrow, et al. JAMA 2010:304:1447-1454

P < 0.001

Witnessed/Shockable

7.8%

Std-CPR

13.3%

COCPR

A. B.All OHCA

AOR 1.6 (95% CI, 1.08-2.35)

Bystander contacted 9-1-1

standard CPR (n=960) chest compression alone (n=981)

Dispatcher-assisted hands-only CPR

2010

Survival to DC11.5% 14.4%

HP CPR (Pit) Crew

Each rescuer is assigned a specific location, role and list of tasks to perform.

Focus on high quality CPR Defibrillator is readied while manual compressions

are being performed. Team Leader ensures overall scene management.

EMS Can Further Improving Cardiac Arrest Outcomes?

Key Elements to HPCPR

• BLS – the first 10 min are critical to successful patient outcomes• Each agency develops roles according to manpower• Continuous chest compressions with minimal interruption• Use available feedback devices/metronome• Alternate compression person every 2 min (200 compressions)• Continue chest compressions when charging an AED or manual

defibrillator• Resume chest compressions immediately after any shock

CPR Dashboard Display

Rate indicator

Perfusion performance

indicator

Depth indicator

Release

ETCO2

CPR Quality

HPCPRIntegrating ALS

• IO vs IV• Epinephrine 1:10,000 1 mg IV / IO

• After first full round of 200 compressions/defibrillation• Repeat with every other cycle of compressions unless in ROSC

• Lidocaine 1.5 mg/kg IV/IO not to exceed 3mg/kg• Refractory VF/VT

• Advanced Airway – wait until ROSC unless airway compromised , BVM inadequate, or available manpower prevents two hand mask seal

• Other medications• Other potential causes- tricyclic OD, renal failure, narcotic OD• Dopamine with ROSC with low BP-STEMI Center Physician Order

Key to success:

Adapt the concepts to your program

POI

P1 P2

Position 1 (P1) -Initial Team Leader

• Initiate compressions 110/min• Alternates compressions with P2 at 200

compression • When not doing compressions and keeps

count of compressions• Provides for Passive Oxygenation Insufflation

(POI) with OPA• Suction airway as necessary

Position 2 (P2)

• Activates Metronome• Applies and operates AED if applicable with

minimal interruption of compressions• Analyze and shock if indicated after each

round of 200 compression• Provide for Passive Oxygenation Insufflation

(POI) with OPA• Alternates with P1 at 200 compression ) • When not doing compressions , keeps count

of compressions

AED

2 Person BLS

P3

P1 P2

AED/ Monitor

Position 3 (P3) BLS/ALS – At patient’s head becomes Team Leader• Assembles and manages airway • BVM , ETCO2, Suctioning• Analyze and shock if indicated after each round of 200

compression

Position 1 (P1) –

• Initiate compressions 110/min• Alternates compressions with P2 at 200 compression • When not doing compressions and keeps count of

compressions• Provides respirations on upstroke of 10th compression and

keeps count of compressions

Position 2 (P2)

• Activates Metronome• Assists with application AED/ALS Monitor with minimal

interruption of compressions• Provides respirations on upstroke of 10th compression and

keeps count of compressions• Alternates with P1 at 200 compression • When not doing compressions and keeps count of

compressions

3 Person

P3

P1 P2

AED/ Monitor

Position 1 (P1) • Initiate compressions 110/min• Alternates compressions with P2 at 200 compression • When not doing compressions and keeps count of

compressions

Position 2 (P2) • Activates Metronome• Applies and operates AED /Monitor• Ventilates 200-400cc every 10 compression• Alternates with P1 at 200 compression /keeping count

4 Person BLS/ALS

Position 3 (P3 ALS)– At patient’s head – Team Leader• Manages airway BVM two hand mask seal• Suctioning - PRN• Apply capnography • Consider oral intubation if airway not compliant, w/

ROSC or after a minimum of 4 -5 rounds of compressions (10-15 min) – do not interrupt compressions

P4 Position 4 (P4 ALS) –outside of the CPR Triangle -May become Team Leader and oversees medication administration• Initiate IV or IO access • Administer medications • Applies monitor- if not done• Analyze for shockable rhythm after 200 compression -

continue with compression while charging• Interacts with Family

How long …

Stay on scene and work the code until:

• ROSC for 5 min – transport to nearest STEMI Center (regardless of 12 lead)

• Refractory V-fib/V-tach – contact STEMI Base Physician for transport to nearest hospital

• If patient arrest during transport – consider STEMI Base Physician for destination to closest hospital

• After 20 min of recitation and no response – call the STEMI Base Physician to terminate

• Consider the auto pulse during transport for the unstable patient• Recognize some circumstances will dictate transporting the non-viable

patient• Exceptions: children and other causes of cardiac arrest i.e. trauma,

drowning, OD, etc.

HPCPR and Mechanical CPR Devices

• Mechanical CPR devices have not demonstrated an increase in survivors over manual CPR

• Goal to minimize interruption in chest compressions during first 10-20 minutes of cardiac arrest is critical, so mechanical CPR device should be delayed

• Mechanical devices should be considered if transporting unstable or refractory V-fib/V-tach patients

How do we monitor our success?

• Real-time feedback• Feedback from monitor/AED• Continuous waveform capnography

• Post-code• Debriefing• QI Review• Benchmarking (Cardiac Arrest Registry for Enhanced Survival

– CARES)

Cardiac arrest performance data

Performance Review: each team member will receive a summary of each code highlighting successes and potential areas for improvement

Successful Programs:

• Measure Outcomes• Provide Feedback• Continuous Improvement Program• Practice regularly

Take Home Points

• Cardiac Arrests Outcomes Can Improve!• BLS CPR quality makes the biggest impact

• Compression rate (110)• Maximize compression depth (>2”)• Allow for full recoil• Minimize pauses (Ideally < 5 sec)

• Minimize ventilations (1:10) (200cc) • Use CPR feedback tools – metronome, capnography• Debrief and review performance• Practice, practice, practice

DEATH TELLING

Death telling

• Assign someone to be the primary communicator with the family

• Be honest and direct• Ask about

support/resources

Time to practice….