In-hospital Cardiac Arrest: First

and foremost,
Chest Compressions

Charles L Campbell MS MD
Associate 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 • Get with the Guidelines
• Survival is 18-20% • 135,896
• There is tremendous – 20% with Ventricular
variability among fibrillation or Ventricular
tachycardia
hospitals
– 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 0.54 <0.0001
insufficiency
Comorbid Cancer 0.50 <0.0001
Arrest time at 0.74 <0.0001
night
Arrest time 0.86 <0.0001
Weekend

JAHA. 2014;3:e000400
JAHA. 2014;3:e000400
 What seems to work?
• Performing ACLS
correctly is associated
with an improvement in
outcome
Resuscitation. 2013;85:82-87
• 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
• Each 10% improvement
in adherance results in a
˜30% increase in ROSC.

Resuscitation. 2013;85:82-87
 What is Happening
• Weisfeldt and Becker
1. Electrical Phase
1. 4 min
2. Defibrillation alone
may be effective
2. Circulator Phase
1. Chest compressions are
necessary
3. Metabolic Phase
4. Stone Heart
JAMA.2002;288:3035-3038
Time course of VF
Circulation. 2005;111:1136-1140 and e294
Hypothermia during VT/VF

J Cardiovascular Magnetic Resonance. 2011;13:17

 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
• 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. 2012;125:3004-12
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