Importance of CPR

Robert S Cole

Contact Information

bull Steve Colebull EMS for 23 yearsbull Ada County Paramedics 15 plus yearsbull CWI bull croaker260gmailcom

Contact Information

bull Steve Colebull EMS for 23 yearsbull Ada County Paramedics 15 plus yearsbull CWI bull croaker260gmailcom

Credit where Credit is Due

bull Adapted from presentation by Ahamed Idris MD ndash Professor of Emergency Medicine University of Texas

Southwestern Medical Center at Dallas

Special Thanks

bull Dr Peter Safarbull Father of Resuscitation

medicinebull Helped develop CPRbull Directly responsible for the

research used in therapeutic hypothermia

RESCOURCESSeattleKCM1 Resuscitation Academy Coursera Online Courses

AHA Resources

Beware of this Start with this

Comic Book

Resuscitatio

n

BEGINNERS PERMIT

bull 2010 ECC Guidelines ndash httpcircahajournalsorgcontent12218_suppl_3toc

Special Thanks

bull Dr Peter Safarbull Father of Resuscitation

medicinebull Helped develop CPRbull Directly responsible for the

research used in therapeutic hypothermia

RESCOURCESSeattleKCM1 Resuscitation Academy Coursera Online Courses

AHA Resources

Beware of this Start with this

Comic Book

Resuscitatio

n

BEGINNERS PERMIT

bull 2010 ECC Guidelines ndash httpcircahajournalsorgcontent12218_suppl_3toc

RESCOURCESSeattleKCM1 Resuscitation Academy Coursera Online Courses

AHA Resources

Beware of this Start with this

Comic Book

Resuscitatio

n

BEGINNERS PERMIT

bull 2010 ECC Guidelines ndash httpcircahajournalsorgcontent12218_suppl_3toc

AHA Resources

Beware of this Start with this

Comic Book

Resuscitatio

n

BEGINNERS PERMIT

bull 2010 ECC Guidelines ndash httpcircahajournalsorgcontent12218_suppl_3toc

BEGINNERS PERMIT

bull 2010 ECC Guidelines ndash httpcircahajournalsorgcontent12218_suppl_3toc

bull 2010 ECC Guidelines ndash httpcircahajournalsorgcontent12218_suppl_3toc

Objectives

bull Importance of maximizing CPRbull Why compressionventilation ratio 302 bull Complete chest wall recoilbull Danger of hyperventilationbull CPR First vs shock firstbull 1 shock vs 3 shocksbull Minimize delay to shock

Why I am doing this lecturehellipWhy I am doing this lecturehellip

A need for changehellip

bull Approximately 350000 persons die from out-of-hospital cardiac arrest each year in North America

bull Survival rate is poor among these patients and most do not survive to hospital discharge

bull New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought

bull Other research suggests that an impedance threshold device (ITD) may improve outcome

CPR in Hollywoodhellip

bull ROSC (Getting a pulse back) 75bull discharged neurologically Intact 67

CPR in Real Life

bull ROSC between 01 and 49ndash 3-7 typical

bull Survival to Hospital Admission 23bull Survival to Discharge 76

ndash THIS HAS NOT IMPROVED SIGNIFICANTLY IN 30YEARSbull Good Neurological Outcome 01 and 30

Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10

2009 doi101161CIRCOUTCOMES1098895 6

Today Nearly everyone dieshellip

But there is hopehellip

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

Breaking the Barrier

bull 50 ROSC in VF arrestndash August 5 1967 Bellfast Scotland

bull 100 ROSC 50 survival to dischargebull (random Fact This was the issue that Dr Ashbaugh first described

ARDS in as well)

ndash Seattle KCM1 in 2011

A MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF MYOCARDIAL INFARCTIONJF Pantridge MC MD Belf FRCPJS Geddes MD BSc BelfThe Lancet - 5 August 1967 ( Vol 290 Issue 7510 Pages 271-273 ) DOI 101016S0140-6736(67)90110-9

Importance Of CPR

10-20 of normal blood flow to the heart

20-30 of normal blood flow to the brain

3 Phase Model

Cardiac Output During CPR

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Why I am doing this lecturehellipWhy I am doing this lecturehellip

A need for changehellip

bull Approximately 350000 persons die from out-of-hospital cardiac arrest each year in North America

bull Survival rate is poor among these patients and most do not survive to hospital discharge

bull New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought

bull Other research suggests that an impedance threshold device (ITD) may improve outcome

CPR in Hollywoodhellip

bull ROSC (Getting a pulse back) 75bull discharged neurologically Intact 67

CPR in Real Life

bull ROSC between 01 and 49ndash 3-7 typical

bull Survival to Hospital Admission 23bull Survival to Discharge 76

ndash THIS HAS NOT IMPROVED SIGNIFICANTLY IN 30YEARSbull Good Neurological Outcome 01 and 30

Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10

2009 doi101161CIRCOUTCOMES1098895 6

Today Nearly everyone dieshellip

But there is hopehellip

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

Breaking the Barrier

bull 50 ROSC in VF arrestndash August 5 1967 Bellfast Scotland

bull 100 ROSC 50 survival to dischargebull (random Fact This was the issue that Dr Ashbaugh first described

ARDS in as well)

ndash Seattle KCM1 in 2011

A MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF MYOCARDIAL INFARCTIONJF Pantridge MC MD Belf FRCPJS Geddes MD BSc BelfThe Lancet - 5 August 1967 ( Vol 290 Issue 7510 Pages 271-273 ) DOI 101016S0140-6736(67)90110-9

Importance Of CPR

10-20 of normal blood flow to the heart

20-30 of normal blood flow to the brain

3 Phase Model

Cardiac Output During CPR

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

A need for changehellip

bull Approximately 350000 persons die from out-of-hospital cardiac arrest each year in North America

bull Survival rate is poor among these patients and most do not survive to hospital discharge

bull New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought

bull Other research suggests that an impedance threshold device (ITD) may improve outcome

CPR in Hollywoodhellip

bull ROSC (Getting a pulse back) 75bull discharged neurologically Intact 67

CPR in Real Life

bull ROSC between 01 and 49ndash 3-7 typical

bull Survival to Hospital Admission 23bull Survival to Discharge 76

ndash THIS HAS NOT IMPROVED SIGNIFICANTLY IN 30YEARSbull Good Neurological Outcome 01 and 30

Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10

2009 doi101161CIRCOUTCOMES1098895 6

Today Nearly everyone dieshellip

But there is hopehellip

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

Breaking the Barrier

bull 50 ROSC in VF arrestndash August 5 1967 Bellfast Scotland

bull 100 ROSC 50 survival to dischargebull (random Fact This was the issue that Dr Ashbaugh first described

ARDS in as well)

ndash Seattle KCM1 in 2011

A MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF MYOCARDIAL INFARCTIONJF Pantridge MC MD Belf FRCPJS Geddes MD BSc BelfThe Lancet - 5 August 1967 ( Vol 290 Issue 7510 Pages 271-273 ) DOI 101016S0140-6736(67)90110-9

Importance Of CPR

10-20 of normal blood flow to the heart

20-30 of normal blood flow to the brain

3 Phase Model

Cardiac Output During CPR

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

CPR in Hollywoodhellip

bull ROSC (Getting a pulse back) 75bull discharged neurologically Intact 67

CPR in Real Life

bull ROSC between 01 and 49ndash 3-7 typical

bull Survival to Hospital Admission 23bull Survival to Discharge 76

ndash THIS HAS NOT IMPROVED SIGNIFICANTLY IN 30YEARSbull Good Neurological Outcome 01 and 30

Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10

2009 doi101161CIRCOUTCOMES1098895 6

Today Nearly everyone dieshellip

But there is hopehellip

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

Breaking the Barrier

bull 50 ROSC in VF arrestndash August 5 1967 Bellfast Scotland

bull 100 ROSC 50 survival to dischargebull (random Fact This was the issue that Dr Ashbaugh first described

ARDS in as well)

ndash Seattle KCM1 in 2011

A MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF MYOCARDIAL INFARCTIONJF Pantridge MC MD Belf FRCPJS Geddes MD BSc BelfThe Lancet - 5 August 1967 ( Vol 290 Issue 7510 Pages 271-273 ) DOI 101016S0140-6736(67)90110-9

Importance Of CPR

10-20 of normal blood flow to the heart

20-30 of normal blood flow to the brain

3 Phase Model

Cardiac Output During CPR

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

CPR in Real Life

bull ROSC between 01 and 49ndash 3-7 typical

bull Survival to Hospital Admission 23bull Survival to Discharge 76

ndash THIS HAS NOT IMPROVED SIGNIFICANTLY IN 30YEARSbull Good Neurological Outcome 01 and 30

Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10

2009 doi101161CIRCOUTCOMES1098895 6

Today Nearly everyone dieshellip

But there is hopehellip

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

Breaking the Barrier

bull 50 ROSC in VF arrestndash August 5 1967 Bellfast Scotland

bull 100 ROSC 50 survival to dischargebull (random Fact This was the issue that Dr Ashbaugh first described

ARDS in as well)

ndash Seattle KCM1 in 2011

A MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF MYOCARDIAL INFARCTIONJF Pantridge MC MD Belf FRCPJS Geddes MD BSc BelfThe Lancet - 5 August 1967 ( Vol 290 Issue 7510 Pages 271-273 ) DOI 101016S0140-6736(67)90110-9

Importance Of CPR

10-20 of normal blood flow to the heart

20-30 of normal blood flow to the brain

3 Phase Model

Cardiac Output During CPR

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Today Nearly everyone dieshellip

But there is hopehellip

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

Breaking the Barrier

bull 50 ROSC in VF arrestndash August 5 1967 Bellfast Scotland

bull 100 ROSC 50 survival to dischargebull (random Fact This was the issue that Dr Ashbaugh first described

ARDS in as well)

ndash Seattle KCM1 in 2011

A MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF MYOCARDIAL INFARCTIONJF Pantridge MC MD Belf FRCPJS Geddes MD BSc BelfThe Lancet - 5 August 1967 ( Vol 290 Issue 7510 Pages 271-273 ) DOI 101016S0140-6736(67)90110-9

Importance Of CPR

10-20 of normal blood flow to the heart

20-30 of normal blood flow to the brain

3 Phase Model

Cardiac Output During CPR

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

But there is hopehellip

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

Breaking the Barrier

bull 50 ROSC in VF arrestndash August 5 1967 Bellfast Scotland

bull 100 ROSC 50 survival to dischargebull (random Fact This was the issue that Dr Ashbaugh first described

ARDS in as well)

ndash Seattle KCM1 in 2011

A MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF MYOCARDIAL INFARCTIONJF Pantridge MC MD Belf FRCPJS Geddes MD BSc BelfThe Lancet - 5 August 1967 ( Vol 290 Issue 7510 Pages 271-273 ) DOI 101016S0140-6736(67)90110-9

Importance Of CPR

10-20 of normal blood flow to the heart

20-30 of normal blood flow to the brain

3 Phase Model

Cardiac Output During CPR

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Breaking the Barrier

bull 50 ROSC in VF arrestndash August 5 1967 Bellfast Scotland

bull 100 ROSC 50 survival to dischargebull (random Fact This was the issue that Dr Ashbaugh first described

ARDS in as well)

ndash Seattle KCM1 in 2011

A MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF MYOCARDIAL INFARCTIONJF Pantridge MC MD Belf FRCPJS Geddes MD BSc BelfThe Lancet - 5 August 1967 ( Vol 290 Issue 7510 Pages 271-273 ) DOI 101016S0140-6736(67)90110-9

Importance Of CPR

10-20 of normal blood flow to the heart

20-30 of normal blood flow to the brain

3 Phase Model

Cardiac Output During CPR

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Importance Of CPR

10-20 of normal blood flow to the heart

20-30 of normal blood flow to the brain

3 Phase Model

Cardiac Output During CPR

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

3 Phase Model

Cardiac Output During CPR

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Cardiac Output During CPR

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

KEY POINT

CPR not PARAMEDICS save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Understanding Chest Compressions

Compressionbull Increased intrathoracic pressurebull Compression of heart and lungs

Decompression (recoil)bull Decreased intrathoracic pressurebull Refilling of heart and lungs

Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Intra-thoracic Pressure and CPR

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

New Cardiac Guidelines (2005)

bull Rate of 100minutebull Depth of 1 12ndash2 inches

ndash (or more in larger people)bull Complete chest recoil after each compressionbull Ventilation (less is more)

ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second

bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to minimize fatigue

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

2005 to 2010 changeshellip

Component of CPR 2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Who does good CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

bull Perceived performance does not always match observed performance

bull Aufderheide et al showed that duty cycle chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance

bull Wik et al showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers and no flow time (when there was neither a pulse nor CPR being given) was almost 50 in directly observed performance evaluations

bull The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75 of patients achieved ROSC with 90 or more chest compressionsminute compared to only 42 with 72 or fewer chest compressionsminute)

THE PAINFUL TRUTH

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

IMPORTANT POINT

bull RATE

bull DEPTH

bull RELEASE

bull UNINTERRUPTED

bull DECREASED VENTILATION

5 KEY ASPECTS

OF GOOD CPR

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Answer NO ONE

Studies showedhellipbull Chest compressions were not delivered about half of the

time (too much ldquohands offrdquo)bull Most compressions were not deep enough

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Compression DEPTH

bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

No-Flow Ratio (Interruption of CPR)

bull Target = less than 20bull Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Compression Rate

bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Compression Ratehellip

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Barriers to staying on the chesthellip

bull Pausing for proceduresndash intubation IV pulse check etc)

bull Pausing for rhythm analysisbull Pausing after shock to await post-shock rhythmbull Pausing to charge clear and shockbull Unaware of importance of CPR in ldquobig picturerdquo

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Get EVERY Compression Right

Critical pressure for ROSC(Paradis et al JAMA19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Cerebral Perfusion Pressures and CPRAbella et al 2005 Circulation

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Current Guidelines for Ventilation

bull CPR with Advanced Airway 8 ndash 10 breathsminute

bull Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Compression-Ventilation Ratio

bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Reality Suckshellip

bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Prolonged Ventilations

bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Everyone sucks

bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute

bull Dallas 30minutebull Tuscan 34minutebull Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Aware of importance of CPR

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

CPR FIRST BEFORE DEFIB

bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

CPR IMPROVING DEFIB

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

CPR Improving EPI

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

DELAYS AND INTERRUPTIONS KILL

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

HOVERING

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

WHERE DOES THE AIRWAY FIT IN

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

bull Hands off period for ETT during CPR estimated at 47 seconds per attempt with some patients losing over 2 minutes of hands off time ndash (Wang Simeone Weaver amp Callaway 2009)

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Intubate DURING CPR

bull Minimal no interruption of compressions

bull More time (up to 2 minutes) to get the tube = better 1st pass success

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Why not a supraperi-glottis airway

bull large study 2005-2007 over 131K patients

bull Compared LMA ETT and EOA

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Why not a supraperi-glottis airway

bull ldquoPrehospital use of supraglottic airway devices was associated with slightly but significantly poorer neurological outcomes compared with tracheal intubation but neurological outcomes remained poor overallrdquo

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Why not a supraperi-glottis airway

bull ldquo EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilationrdquo

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Cric Pressure (Really)

bull Cricoid pressure in non-arrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

bull However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

bull If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

bull The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

FiO2 (During Arrest)

bull Use of 100 inspired oxygen (FIO2 10) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

FiO2 (post arrest)

bull Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injuryndash Hyper-oxia defined as PaO2 gt300 cm H2O

bull Exact FiO2 recommendations have not been determined bull In the post arrest phase if equipment is available titration of FiO2

to SPO2 94-99 is recommended (Class I LOE C)ndash Dependent on individual factors

bull This may not apply to other life-threatening states

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Passive O2 delivery during arrestbull Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has

been reviewed bull In theory because ventilation requirements are lower than normal during cardiac arrest

oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

bull The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

bull At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

NC at 15 LPMbull Principle of ldquoApniec Diffusionrdquobull FiO2 w NRB at 60-70 with 15 LPM

alone bull Using high flow via NC will improve SPO2

over NRB alonendash Works best with bilat NPArsquos

bull Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion even as carbon dioxide builds up in the blood

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

CPR Whats Next

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

bull 90 of all changes to 2010 ECC are right in the BLS segment

bull Builds on and further enhances the changes and research discussed in the 2005 guidelines

bull COMPRESSIONS are the single most emphasized segment of resuscitation

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Hands Only CPR

bull Single biggest changebull ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons and non HCP first responders

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

KEY POINT

bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

New CPR Guidelines

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Traditional Healthcare Version

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

CAB

bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Pulse Check

bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Look Listen and Feel

bull Confusion in Agonal Respirations vs Good Respirationsbull ldquoLook Listen and Feelrdquo de- emphasized

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

ADJUNCTS IN CPR

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

CPR Prompts

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

FEEDBACK

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

CPR FeedbackCPR FEEDBACK

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Adjuncts to Circulation

bull Impedance threshold device (ITD)ndash Valve device placed

between endotracheal tube and bag-mask device

ndash Limits air entering lungs during recoil phase between chest compressions

Courtesy of Advanced Circulatory Systems Inc

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Impedance Threshold Device (ITD)

bull Used both with ETT Face Mask and other advanced Airways

bull The ITD limits air entry into the lungs

bull during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

bull Major reviews have shown some survival to hospital improvement but this may be multi-factorial

bull The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Active Compression-Decompression CPR (ACD-CPR)

bull Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

bull ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Adjuncts to Circulation

bull Mechanical piston devicendash Depresses

sternum via compressed gas-powered plunger

bull Load-distributing band CPR or vest CPRndash Composed of

constricting band and backboardCourtesy of Jolife AB

Cou

rtes

y of

ZO

LL

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Mechanical Piston Devices

bull LUCAS THUMPER ETCbull In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

bull No long term benefit over manual CPR discovered (yet)

bull There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

bull Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

bull Auto-Pulse is the most commonbull Initial repots were very positive

however a large study showed poor neurological outcomes

bull Further studies pending bull The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

bull However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Therapeutic Hypothermia

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Therapeutic Hypothermia

bull CLASS I Intervention for witnessed VF VT arrestsndash Class IIa intervention or asytolic and un-witnessed arrests

bull MILD Hypothermia ndash Exact temp debatablendash 33 C (93 F) to 36 C (96 F)

bull Significantly improves outcomesbull Only works if continued by hospitals

ndash New York FDEMS experience

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

EMS hypothermia not usefulbull SeattleKC trial ndash 1359 patientsbull Short transport times ALL patients in this study received

in hospital cooling bull Did not evaluate systems with longer transport times less

robust in hospital SCA responsebull Did not evaluate likely hood of patients receiving cooling

without pre-hospital cooling (FDNY experience)

Kim F Nichol G Maynard C et al Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest A randomized clinical trial JAMA 2013

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

The Future

bull Increased focus on the ldquoMetabolic Phaserdquobull Cardiac ByPassbull Mitochondrial medicine

ndash Stabilizing the ldquoApotic Switchrdquobull Ion Channel bull Deep Hypothermia

ndash Trauma Studies Ongoing

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

PIT CREW CPR

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Compress

gt 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120min

Improved survival

Switch compressors every 2 min Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

12

3

CPR 1

CPR 2 AED

AIRWAYVENTILATION

BLS PIT CREW MODEL

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADER

DEFIB-IVIO-MEDSCPRCPR

VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

ALS PIT CREW MODEL

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

PARAMEDICS GIVE AWAY THE TUBE

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

Checklist Medicine

bull Derived from the Airline Industry

bull Oh Crap checklist not step by step checkists

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

bull EMTs own CPR Medics Own ldquoEverything elserdquobull Minimize interruptions in CPR at all timesbull Ensure proper depth of compressions (gt2 inches)bull Ensure full chest recoildecompressionbull Ensure proper chest compression rate (100-120min)bull Rotate compressors every 2 minutes bull Hover hands over chest during shock administration and be ready to compress as soon as patient is clearedbull Intubate or place advanced airway with ongoing CPRbull Place IV or IO with ongoing CPRbull Coordination and teamwork between EMTs and paramedics

IN CLOSING

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

ldquoIt is up to us to save the worldrdquo- Peter Safar

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109

• Importance of CPR
• Contact Information
• Credit where Credit is Due
• Special Thanks
• RESCOURCES
• AHA Resources
• Slide 7
• Slide 8
• Objectives
• Why I am doing this lecturehellip
• A need for changehellip
• CPR in Hollywoodhellip
• CPR in Real Life
• Today Nearly everyone dieshellip
• But there is hopehellip
• Breaking the Barrier
• Importance Of CPR
• 3 Phase Model
• Cardiac Output During CPR
• Slide 20
• KEY POINT
• Understanding Coronary Perfusion Pressure
• Understanding Chest Compressions
• ROSC Associated with CPP
• Benefit of Continuous Chest Compressions
• Intra-thoracic Pressure and CPR
• New Cardiac Guidelines (2005)
• 2005 to 2010 changeshellip
• Who does good CPR
• Answer NO ONE
• Slide 31
• IMPORTANT POINT
• Answer NO ONE (2)
• Compression DEPTH
• No-Flow Ratio (Interruption of CPR)
• Compression Rate
• Compression Ratehellip
• Compression Ratehellip (2)
• Barriers to staying on the chesthellip
• Importance of complete recoil
• Get EVERY Compression Right
• Cerebral Perfusion Pressures and CPR
• Current Guidelines for Ventilation
• Compression-Ventilation Ratio
• Reality Suckshellip
• Prolonged Ventilations
• Everyone sucks
• Effect of Vent Rate on CPP
• Aware of importance of CPR
• Slide 50
• CPR FIRST
• CPR FIRST BEFORE DEFIB
• CPR IMPROVING DEFIB
• Slide 54
• CPR Improving EPI
• Slide 56
• Slide 57
• Slide 58
• WHERE DOES THE AIRWAY FIT IN
• Slide 60
• Intubate DURING CPR
• Why not a supraperi-glottis airway
• Why not a supraperi-glottis airway (2)
• Why not a supraperi-glottis airway (3)
• Cric Pressure (Really)
• FiO2 (During Arrest)
• FiO2 (post arrest)
• Passive O2 delivery during arrest
• NC at 15 LPM
• CPR Whats Next
• Slide 71
• Hands Only CPR
• Slide 73
• KEY POINT
• New CPR Guidelines
• Traditional Healthcare Version
• CAB
• Pulse Check
• Look Listen and Feel
• Adjuncts in CPR
• CPR Prompts
• Slide 82
• Slide 83
• CPR Feedback
• Adjuncts to Circulation
• Impedance Threshold Device (ITD)
• Active Compression-Decompression CPR (ACD-CPR)
• Adjuncts to Circulation (2)
• Slide 89
• Mechanical Piston Devices
• Load-Distributing Band CPR or Vest CPR (LDB-CPR)
• Therapeutic Hypothermia
• Therapeutic Hypothermia (2)
• EMS hypothermia not useful
• The Future
• PIT CREW CPR
• Slide 97
• Slide 98
• Slide 99
• Slide 100
• Slide 101
• Slide 102
• Slide 103
• Slide 104
• PARAMEDICS GIVE AWAY THE TUBE
• Checklist Medicine
• Slide 107
• Slide 108
• Slide 109