High Quality CPR;

Why Do We Care &

Controversies on Pre-hospital System

Ali Haedar, MD, SpEM, FAHA

Clinical lecturer & Emergency Medicine Specialist

Department of Emergency Medicine

Faculty of Medicine – University of Brawijaya
Saiful Anwar General Hospital
Cardiac arrest

Electrical recording
of the heart rhythm:

In cardiac arrest, abrupt and total loss of cardiac output

Uniformly fatal unless immediate treatment given (e.g. CPR)

Cardiac arrest epidemiology in the US

400,000 arrests / year

2/ 3 1/ 3
Out-of-hospital In-hospital

survival to
hospital
1-5% discharge 10-20%
Mortality from cardiac arrest

arrest
% Surviving

CPR
defibrillation

ROSC

hospital
discharge
Time
Development of chest compressions

Drs. Knickerbocker, Kouwenhoven, and Jude –

Johns Hopkins, 1950s – studied defibrillation
and chest compressions in the laboratory
Approaching 50 years of modern CPR

A B

A. Peter Safar, 1950s

B. Early symposium on CPR 1961

RECOMMENDATIONS AND CHANGES
FOR BLS AT HOSPITAL

Include updated information and

scientific rationale on the following
• Immediate recognition and activation
of Code Blue Team
• Emphasis on High Quality CPR
• Shock first vs CPR first
• Minimizing interruptions in
chest compressions
• Ventilation during CPR with
an advanced airway — all ages
What constitutes quality CPR?

• Depth of Compressions

• Correct Rate of Compressions

• Recoil

• Minimizing interruptions

• Early Defibrillation
Chest compression alone CPR
Dispatch-assisted CPR and AED use

If someone calls 911 and doesn’t know CPR

or how to use an AED, the dispatcher can
coach them on the spot

Growing concept across the US

Recent publication from the American Heart Association,

endorsing the use of dispatch 911 CPR instructions:

Is patient conscious?
Sample algorithm
“no”
for dispatch recognition
Is patient breathing normally? of cardiac arrest
“no”

STARTCPR; INSTRUCTIONS
Lerner et al, Circulation 2012
Chest compression alone CPR

Bystander contacted 9-1-1

standard CPR (n=279) chest compression alone (n=241)

29/279 (10.4%) 35/241 (14.6%)

p=0.18
Improvement due to:
? less time to train
? better CPR strategy

Hallstrom et al, 2000

Chest compression alone CPR:revisited

2010
Bystander contacted 9-1-1

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

11.5% 14.4% (OR 2.9)

Survival to Discharge
Unrealistic to ventilate well?

1996

Ventilation was the biggest

technical challenge for
lay rescuers

Mouth-to-mouth is HARD
Compression-only: training is easier

2012

Lay public feels more

Confident with Chest
Compression only

More willing to share

Information with others
Standard CPR vs Chest Compression alone
Blood pressure

Time
= chest compression
Berg et al, 2001
Standard CPR vs CC alone
Blood pressure

Time
= chest compression
Berg et al, 2001
“No flow” / compression fraction
30
Survival to discharge, %
20

Christenson J et al, Circ 2009

10

poor survival with lowest

compression fraction in OHCA
0

0-20 21-40 41-60 61-80 81-100

comp fraction, %
Chest compression depth

40 2 inches vs 1.5 inches

Surviva l:
32
CPP, mm Hg

100%
24

16

8 15%
0
1 2 3
CPR duration, min
ICCM, 2005
Chest compression depth

CCM 2012
CPR quality a n d survival

2013

Rate of 90-100 may be best;

too slow or too fast may yield
worse outcomes
CPR quality a n d survival

2013

Deeper compressions
Favors survival; no max
Depth identified
CPR first may improve survival

Influence of cardiopulmonary resuscitation prior

to defibrillation in patients with out-of-hospital
ventricular fibrillation

24% (155/639) 30% (142/478) p =0.04

Defib first - AHA CPR (90 sec) first, then defib

42 months 36 months

Cobb et al, 1999

CPR first may improve survival: RCT

0.5
CPR first
probability of survival

Standard care
0.4

0.3

0.2

0.1
p=0.006
0

0 2 4 6 8 10 12 14
time from collapse, min
Wik et al, 2003
CPR sensing a n d recording defibrillator

Similar defibrillators now m a d e by both Philips a n d Zoll

Chest compression rates
300
n=1626 segments
Number of 30 sec segments

250

200

150

100

50

0
10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 R>120

Chest compression rate (min-1)

Abella et al, 2005

Chest compression rates by survival
Mean rate, ROSC group
210
90 ± 17 *
Number of 30 sec segments

p=0.003
180 Mean rate,
no ROSC group
150
79 ± 18 *
No ROSC
120
ROSC
90

60

30

0
10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 >120

Chest compression rate (min-1)

Abella et al, 2005
CPR renaissance: measuring CPR

Valenzuela et al, Circ 2005

Wik et al, JAMA 2005
Abella et al, JAMA 2005
Aufderheide et al,Circ 2004
Hyperventilation during EMS resuscitation

16 seconds

v v v v v v v v v v

mean ventilation rate: 30 ± 3.2

first group: 37 ± 4 after retraining: 22 ± 3

Aufderheide et al, 2004

Chest compression pauses before shocks

4:55 5:00 5:05 5:10

ECG
Compressions

Pause before shock

Dose-effect of pre-shock pauses
VF removed, percent
100
p=0.003
90%
80

60 64%
55%
40

20
10%
0
≤10.3 10.5-13.9 14.4-30.4 ≥33.2
(n=10) (n=11) (n=11) (n=10)
Pre-shock pause, seconds

Edelson et al, 2006

Possible model underlying these data
Current CPR quality: summary

1. Slow compression rates

2. Frequent and lengthy pauses
3. Shallow compressions
4. Hyperventilation
AHA statement on CPRquality

2013
Concept of “report cards” for resuscitation
Improving EMS care with “CC only”

Bobrow et al, 2008

Interventions:
1. Significantly delay intubation
2. 200 compressions before first shock
3. Minimize pre and post shock pauses

Tripled survival to hospital discharge (3.8% àà9.1%)

The key importance of CPR
Reflected in the poor impact of ACLS meds:

2009

Randomized trial of epinephrine versus no epinephrine

For EMS treated cardiac arrest ààNO SURVIVALBENEFIT!
Assessment during CPR is poor

In 2010, few options available to obtain

“output” from patients during resuscitation

Treatment Effects
(input) (output)
Patient receiving care
Assessment during CPR is poor

In 2010, few options available to obtain

“output” from patients during resuscitation

Treatment Effects
(input) (output)
Patient receiving care
Temp curve
antibiotics wbc count
Patient with pneumonia
Progress in resuscitation inputs/outputs

CPR quality emphasis

30:2 CPR
Quality

CPR introduced

Pulse check Pulse check Pulse check

Rhythm strip Rhythm strip Rhythm strip

Time (years)
How about in the pre-
hospital setting?
 Mechanical CPR

Load Distributing Band Mechanical Piston

 Mechanical CPR

Survival with Good Neurologic Function (mRS ≤3 or CPC 1-2)

10,0%
8,0%
6,0%
4,0%
2,0%
0,0%
to al

to al

LU l

LU l
S

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lse

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ua

ua
CA

CA
Au nu

Au nu
pu

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an

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Hallstrom Wik Rubertsson Perkins
JAMA Resus JAMA Lancet
2006 2014 2014 2015
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
Key “take home” points

1. Cardiac arrest is not hopeless!

2. CPR quality has big impact

3. Minimize ventilations

4. Maximize chest compression rate and depth

5. Mechanical chest compressors have not

been demonstrated to be helpful
08123317226
alihaedar.fk@ub.ac.id

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