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CPR:Push Hard(er), Push Fast(er)
Mike McEvoy, PhD, NRP, RN, CCRN
EMS Coordinator – Saratoga County, NY
EMS Editor – Fire Engineering magazine
Chair – Resuscitation Committee – Albany Medical Center Hospital – Albany, New York
www.mikemcevoy.com
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Disclosures• I am on the Physio-Control Speakers
Bureau
• I don’t know how to play golf or ski
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www.mikemcevoy.com
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Outline• CPR 2010: that was then, this is now…
• Show me the money: is there proof?
• What matters?
• Why measure?
• How to assessquality CPR
• Unique hospitalissues
• Future solutions
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Adult Chain of Survival: 20101. Immediate recognition and activation of
emergency response system2. Early CPR with emphasis on
chest compressions3. Rapid defibrillation4. Effective ALS5. Integrated post-cardiac arrest care
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CPR SequenceChange A-B-C to C-A-B Initiate chest compressions
before ventilations
Why? Reduce delay to
compressions Can be started immediately Emphasizes importance of
chest compressions
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So, What Matters in CPR?And how should we assess effectiveness?
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Chest Compressions
2010• > 50 mm ( > 2”)• At least 100 per minute
2005• 38 – 51 mm (1.5 – 2”) • 100 per minute
Most Common Errors:1.Too slow2.Not deep enough3.Prolonged interruptions4.Leaning
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Chest Compressions• ROC: survival associated with depth• Abella et al: 100-120/min = survival• Recommendations are both Class I, LOE C (just do it, because we like it)• In truth:
– Ideal actual depth of CPR unknown• Probably lies near 50 mm
– Best rate for CPR unknown• Is likely about 100/min
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CPR Rate vs. ROSC
p < 0.0083
Abella et al. Circulation. 2005;111:428-434
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Probability of ROSC
Stiell et al. Crit Care Med 2012; 40:1192-1198
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One Day Survival
Stiell et al. Crit Care Med 2012; 40:1192-1198
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Survival to Discharge
Stiell et al. Crit Care Med 2012; 40:1192-1198
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Effective CPR?• How do you measure the effectiveness
of CPR?– End tidal carbon dioxide– Feedback devices
• Measurement of CPR effectiveness is a proposed TJC future standard
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Waveform CapnographyAttaches to ET tube, measures CO2
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Oxygen Lungs alveoli blood
Muscles + Organs
Oxygen
Cells
Oxygen
Oxygen+
Glucose
ENERGY
CO2
Blood
Lungs
CO2
Breath
CO2
Physiology of Metabolism
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SpO2 versus EtCO2
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Oxygenation and VentilationOxygenation (Pulse Ox)
– O2 for metabolism
– SpO2 measures % of O2 in RBCs
– Reflects changes in oxygenation within 5 minutes
Ventilation (Capnography)
– CO2 from metabolism
– EtCO2 measures exhaled CO2 at point of exit
– Reflects changes in ventilation within 10 seconds
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Measuring Exhaled CO2
Colorimetric
Capnometry
Capnography
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Measuring Exhaled CO2
Colorimetric
Capnometry
Capnography
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Measuring Exhaled CO2
Colorimetric
Capnometry
Capnography
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Capnography Waveforms
45
0
45
0
Hypoventilation
Normal
Hyperventilation
45
0
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98
Sp02
What about the Pulse Ox?
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Carbon Dioxide (CO2) Production
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What If…
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But, with High-Quality CPR…
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Meet Howard Snitzer• 54-years old, collapsed Jan 5,
2011 outside Don’s Foods in Goodhue, MN (pop. 900)
• 2 dozens rescuers took turns providing CPR for 96 minutes
• 6 shocks with first responder AED, 6 more shocks by Mayo Clinic Air Flight Medics
• Transported to Mayo Clinic Cardiac Cath Lab
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Why Not Quit?• Thrombectomy, stent to LAD
• 10 days inpatient
• “The capnography told us not to give up”
• EtCO2 averaged 35 (range 32 – 37)
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So What’s the Goal During CPR?
• Try to maintain a minimum EtCO2 of 10
• Push HARD (> 2”)FAST (at least 100)
• Change rescuerEvery 2 minutes
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Guidelines 2010• Continuous quantitative waveform
capnography recommended for intubated patients throughout peri-arrest period. In adults:
1. Confirm ETT placement
2. Monitor CPR quality
3. Detect ROSC with EtCO2 values
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Guidelines 2005EtCO2 recommended to confirm ET
tube placement
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Wayne MA, Levine RL, Miller CC. “Use of End-tidal Carbon Dioxide to Predict Outcome in Prehospital Cardiac Arrest” . Annals of Emergency Medicine. 1995; 25(6):762-767.
Levine RL., Wayne MA., Miller CC. “End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest.” New England Journal of Medicine. 1997;337(5):301-306.
EtCO2 detects ROSC• 90 pre-hospital intubated arrest patients• 16 survivors
• 13 survivors: rapid rise in exhaled CO2 was the earliest indicator of ROSC
• Before pulse or blood pressure were palpable
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Capnography = Results, not process
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Guidelines 2010: EvidenceCapnography Classes & Levels of Evidence:
1. Confirm ETT placement: Class I, LOE A
2. Monitor CPR quality: Class IIb, LOE C
3. Detect ROSC with EtCO2: Class IIa, LOE B
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Classes of EvidenceI – Standard of care: just do it!
II – Conflicting evidence: maybe or not
IIa – evidence favors benefit – do it
IIb – evidence not so favorable – think first
III – Not useful, maybe harmful: don’t do it
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Levels of Evidence: ProofA – A whole lotta proof: best!
B – Some proof: better than nothing
C – No proof: but some like the idea
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Guidelines 2010: EvidenceCapnography Classes & Levels of Evidence:
1. Confirm ETT placement: Class I, LOE A
Just do it, best proof
2. Monitor CPR quality: Class IIb, LOE C
Think first, some like the idea
3. Detect ROSC with EtCO2: Class IIa, LOE B
Do it, better than nothin’
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CPR is Complicated!
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Hospital Issues:
1. Bed Height– Optimal = bed at knee level of person
administering chest compressionsCho et al, Emerg Med J. 2009;26:807-810
2. Air Mattresses– No need to deflate mattress for CPR
Perkins et al, Inten Care Med. 2003;29:2330-2335
3. Backboards– No evidence of benefit with backboard
Perkins et al, Inten Care Med. 2003;29:2330-2335
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What About Quality?
In-Hospital Arrests, Dec 2004 – Dec 2005
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Audiovisual CPR Feedback
• Incorporated into monitor/defibrillator
• Real time
• Accelerometer-based
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Handheld Feedback Device
Handheld accelerometer-based audiovisual device
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Generation of Feedback
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Post Code Reviews
(Code Stat ™)
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EMS Feedback = ROSC• FDNY uses audio-visual feedback
• Deactivated audio feedback for 1 week
• ROSC 20% NY State EMS Council Report Jan 2012
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But Hospitals ≠ EMS
• How effective are feedback systems?
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We have a problem:
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Accelerometer CPR Depth
Perkins et al. Resuscitation 2009;80:79-82
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The Mattress Issue:• Mattress compression = 35 – 40% of
total compression depth
• Accelerometer feedback devices fail to account for mattress compression
• Use of a backboard fails to compensate for mattress compression
Perkins et al. Resuscitation 2009;80:79-82
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The Solution:
Directly measurethe true
compression depth.
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• Two end points• Direct measurement of distance (magnetic)• Discrimination of X, Y, Z• Accommodation of Roll, Pitch and Yaw
Triaxial Field Induction
11
22
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TFI versus ACC
Banville et al. Circulation 2011; 124:A217
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Summary• Compressions are key to outcomes
– Most common errors: depth and speed
• Need to assess effectiveness of CPR– It improves survival– Future TJC requirement
• Current tools: EtCO2 and ACC
– CO2 delayed
– ACC inaccurate
• Future: TFI – Very promising