in-hospital cardiac arrest: first and foremost, chest compressions charles l campbell ms md...

In-hospital Cardiac Arrest: First and foremost,

Chest Compressions

Charles L Campbell MS MDAssociate Professor of Medicine

University of Kentucky College of Medicine

• No Disclosures

Outline

• IHCA• Hospitals Vary in Outcome• Why• What is recommended• How should it be done• Does it really matter

IHCA is pretty common…

• ˜200,000 in the US• Survival is 18-20%• There is tremendous

variability among hospitals

• Get with the Guidelines• 135,896– 20% with Ventricular

fibrillation or Ventricular tachycardia

– 64% occur in an ICU

• Median Survival Varies– 8.3% at the lowest

Decile– 31.4 at the highest

JAHA. 2014;3:e000400

JAHA. 2014;3:e000400

Clinical Feature Odds Ratio P

VT/VF 3.14 <0.0001

PEA 1.06 0.002

Etiology Toxicologic 2.36

ICU 1.60 <0.0001

Monitored 1.72 <0.0001

Comorbid Hepatic insufficiency

0.54 <0.0001

Comorbid Cancer 0.50 <0.0001

Arrest time at night

0.74 <0.0001

Arrest time Weekend

0.86 <0.0001

JAHA. 2014;3:e000400

JAHA. 2014;3:e000400

What seems to work?

• Performing ACLS correctly is associated with an improvement in outcome

• MUSC study• Compared guideline

adherence for survivors vs. non-survivors– 75 survivors– 75 non-survivors

• Survivors older and with more cormorbidities

Resuscitation. 2013;85:82-87

Resuscitation. 2013;85:82-87

Resuscitation. 2013;85:82-87

Resuscitation. 2013;85:82-87

Resuscitation. 2013;85:82-87

• Each 10% improvement in adherance results in a ˜30% increase in ROSC.

Resuscitation. 2013;85:82-87

What is Happening

• Weisfeldt and Becker1. Electrical Phase

1. 4 min2. Defibrillation alone

may be effective

2. Circulator Phase1. Chest compressions are

necessary

3. Metabolic Phase4. Stone Heart

JAMA.2002;288:3035-3038

Time course of VF

Circulation. 2005;111:1136-1140 and e294

J Cardiovascular Magnetic Resonance. 2011;13:17

Hypothermia during VT/VF

What is Recommended

• Defibrillation• Chest Compressions• Oxygenation• Medications• Procedures

NEJM 2008;358:9-17

Chest Compressions

• Place patient on a firm surface– Backboard– Deflation of air mattress

• Had in the middle of the chest– 5 cm of depression– Allow complete recoil• Lifting the hand completely of the chest can improve

recoil

Circulation. 2010;122:S685-705

How Fast

• Rate 100-120 cpm• Deliver >80 per minute– That means minimal interruption

• Duty Cycle– Time between the start of one compression and

the start of the next – Target is 50%– As much time relaxing as compressing

Circulation. 2010;122:S685-705

Circulation. 2005;428-434

Circulation. 2005;428-434

Circulation. 2005;428-434

Circulation. 2012;125:3004-12

• ROC consortium (9 sites)• OHCA in which monitors/defib measured chest compression

rates• 3098 cases analyzed

Circulation. 2012;125:3004-12

Circulation. 2012;125:3004-12

Compression rate vs Compressions Delivered

Circulation Qual Outcomes.2013;6:148-156

Compression Depth

Resuscitation. 2005;64:363-372

Circulation Qual Outcomes.2013;6:148-156

Recoil Matters…

Resuscitation. 2006;71:341-351

Resuscitation. 2006;71:341-351

Resuscitation. 2006;64:353-362

Circulation Qual Outcomes.2013;6:148-156

Resuscitation, 2007;73:54-61

Resuscitation, 2007;73:54-61

Resuscitation, 2007;73:54-61

Resuscitation. 2009;80:743-751

Non-Shockable Rhythms

Circulation. 2012;125:1787-94

Circulation. 2012;125:1787-94

Chest Compressions and Defibrillation

Resuscitation. 2006;71:137-145

Resuscitation. 2006;71:137-145

• Survival from OHCA improved after the implementation of a protocol that required 90 seconds of CPR prior to the delivery of a shock via an AED– 24% to 30% – Particularly in those in whom the intial response interval was > 4 min.

JAMA. 1999;281:1182-1188

Resuscitation. 2008;77:10-15

Resuscitation. 2008;77:10-15

Resuscitation. 2008;77:10-15

Mechanical CPR?

Conclusions

• Chest Compressions are the cornerstone of resuscitation– Rate– Depth– Recoil– Minimizing Interruptions – Feedback is probably helpful

• In some cases chest compressions aid defibrillation• Mechanical chest compressors have not been

demonstrated to be helpful