CPR: Push Hard(er), Push Fast(er)

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CPRPush 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 dont 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 2010

1. Immediate recognition and activation of emergency
   response system
2. Early CPR with emphasis onchest compressions
3. Rapid defibrillation
4. Effective ALS
5. Integrated post-cardiac arrest care

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CPR Sequence

• Change
• 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

• 2005

• gt 50 mm ( gt 2)
• At least 100 per minute

• 38 51 mm (1.5 2)
• 100 per minute

• Most Common Errors
• Too slow
• Not deep enough
• Prolonged interruptions
• 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 lt 0.0083
Abella et al. Circulation. 2005111428-434
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Probability of ROSC

• Stiell et al. Crit Care Med 2012 401192-1198

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One Day Survival

• Stiell et al. Crit Care Med 2012 401192-1198

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Survival to Discharge

• Stiell et al. Crit Care Med 2012 401192-1198

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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 Capnography

• Attaches to ET tube, measures CO2

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Physiology of Metabolism
Oxygen ? Lungs ? alveoli ? blood
Oxygen
Breath
CO2
Muscles Organs
Lungs
Oxygen
CO2
Cells
ENERGY
Blood
Oxygen Glucose
CO2
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SpO2 versus EtCO2
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Oxygenation and Ventilation

• Oxygenation (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
Normal
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0
Hyperventilation
45
0
Hypoventilation
45
0
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What about the Pulse Ox?
Sp02
98
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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 Dons
  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 Whats the Goal During CPR?

• Try to maintain a minimum EtCO2 of 10
• Push
• HARD (gt 2)
• FAST (at least 100)
• Change rescuer
• Every 2 minutes

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Guidelines 2010

• Continuous quantitative waveform capnography
  recommended for intubated patients throughout
  peri-arrest period. In adults
• Confirm ETT placement
• Monitor CPR quality
• Detect ROSC with EtCO2 values

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Guidelines 2005

• EtCO2 recommended to confirm ET tube placement

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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

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. 1997337(5)301-306.
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Capnography Results, not process
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Guidelines 2010 Evidence

• Capnography Classes Levels of Evidence
• Confirm ETT placement Class I, LOE A
• Monitor CPR quality Class IIb, LOE C
• Detect ROSC with EtCO2 Class IIa, LOE B

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Classes of Evidence

• I 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 dont do it

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Levels of Evidence Proof

• A 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 Evidence

• Capnography Classes Levels of Evidence
• Confirm ETT placement Class I, LOE A
• Just do it, best proof
• Monitor CPR quality Class IIb, LOE C
• Think first, some like the idea
• 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

• Bed Height
• Optimal bed at knee level of person
  administering chest compressions Cho et al,
  Emerg Med J. 200926807-810
• Air Mattresses
• No need to deflate mattress for CPR Perkins et
  al, Inten Care Med. 2003292330-2335
• Backboards
• No evidence of benefit with backboard Perkins
  et al, Inten Care Med. 2003292330-2335

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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 20098079-82

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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 20098079-82
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The Solution

• Directly measurethe true compression depth.

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Triaxial Field Induction
1
2

• Two end points
• Direct measurement of distance (magnetic)
• Discrimination of X, Y, Z
• Accommodation of Roll, Pitch and Yaw

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TFI versus ACC
Banville et al. Circulation 2011 124A217
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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