HIGH PERFORMANCE CPR PREHOSPITAL GUIDE TO IMPROVING RESUSCITATION

LEARNING OBJECTIVES Overview of Heart Disease in the United States: Current Data on Out of Hospital Cardiac Arrest Survival (OHCA) Review the principles and value of good quality CPR Outline the American Heart Association “Pit Crew CPR” concept Discuss the CPR concepts of compression fractions and limited pauses in CPR Demonstrate Pit Crew CPR using a 15 minute scenario

HEART DISEASE *Heart disease: Leading cause of death in U.S. *Centers for Disease Control (CDC) reports over 611,105 people die annually from heart disease in U.S. Compared to US Combat Deaths: 405,309 in WWII 90,220 in Vietnam 6,852 in Iraq and Afghanistan **Nearly half of all combat deaths in U.S. History every year** (sources: CDC, Dept. of Veterans Affairs, DOD, and PBS)

Source: org/cpr-statistics/ 99% of Americans need to improve their heart health Lowering your B/P reduces risk by 50% Each year 785,000 Americans have their 1 st heart attack Every 39 sec someone dies from Heart disease and Stroke

AHA OHCA STATISITICS-2015 EMS Assessed OHCA Victims – 326,200 which is appx 60% of all OHCA in U.S. As many as 25% of victims are ASYMPTOMATIC prior to SCA Among EMS assessed- 23% have an initial shockable rhythm (VF/VT) Median age of OHCA is 66 years old Witnessed arrests occur in 38% of cases by bystanders and 10.9% by EMS Up to 50% go unwitnessed As much as 70% occur in the home. Source: American Heart Association, 2015

2015 AHA SCIENCE UPDATE Continued focus on Back to the Basics Adult 30:2 Compression to Ventilation Ratio Simultaneously check breathing/pulse <10 Sec. Depth b/n inches; Allow for full recoil Use AED/DEFIB as soon as possible Avoid: Excessive ventilations Excessive Pauses

2015 SCIENCE UPDATE (CONT.) Children (1yo – puberty) Compression to Ventilation Ratios: 1 person: 30:2 2 person: 15:2 Depth: 1/3 Anterior Posterior (about 2 inches) Simultaneously check for breathing/pulse <10 sec. Use AED/Defib as soon as possible (Child pads/child key) Infant Compression to Ventilation Ratios: 1 person: 30:2 2 person: 15:2 Depth: 1/3 Anterior Posterior (about 2 inches) Simultaneously check for breathing/pulse <10 sec. Use AED/Defib as soon as possible (Child pads/child key)

ADDITIONAL CHANGES Narcan Administration recommended for possible opiate overdoses (BLS) Low ETCO2 after 20 minutes may be an indication of failed resuscitation (ILS/ALS) Target ETCO2 should be greater than 20cm/Hg

WHAT CONSTITUTES QUALITY CPR? Depth of Compressions Correct Rate of Compressions Minimizing interruptions Early Defibrillation

CHEST COMPRESSION DEPTH STUDY Kramer-Johansen, et, al., in 2006 Depth at least 4cm (2 in) increased survival rates Stiel, et al., found an inverse relationship between depth and rate ***Faster the rate, shallower the depth**

COMPRESSION FRACTION (CF)

COMPRESSION FRACTION CONT. Compression Fraction (CF) Target Prehospital CF should be > 0.6 or at least 60% of the time. Some studies are showing that CF > than 80% have significant increases in outcomes Compressions Ventilations Source: Beesems, et al., 2013

STILL MORE CCF… Christenson, et al., linked compression fraction to survival rate Figure on the right shows the highest survival rate among the group that received a CF between 60-80%. A CF of 80% means a total of 24 seconds in pauses in a 2 minute period Jim Christenson et al. Circulation. 2009;120:

LET’S TALK PAUSES Christenson, et al., found that the total time not doing chest compressions (pauses) are linked to survival…but what about any 1 pause? The answer is yes! Latest study: 2015 Brouwer, et al., showed that the longest pause can indicate survival

THE LONGEST PAUSE… Here is a figure from Brouwer, et al. It compares survival rates with the longest pause. When the longest pause is less than (<) 20 seconds, survival rate is nearly 60% in their study!

LET’S PAUSE A “MOMENT” Where do we pause the most in Cardiac Arrest Management? 1.Airway insertion5. Rhythm checks 2.Immobilization6. AED/Defib Charging 3.Pt movement7. Post Shock 4.Pulse Checks

VENTILATIONS AND RESUSCITATION 2015 Guidelines Once advanced airway is in place (ETT, Combitube, King, LMA) perform continuous compressions at rate b/n and ventilate 1 every 6 seconds (10 breaths/min) Why the change? Turns out it’s about pressure!

VENTILATIONS (CONT.) Normal Spontaneous Breathing Patients Create a vacuum in the chest causing them to inhale Causes exhalation without work Known as a NEGATIVE pressure system When we provide Positive Pressure Ventilations We force air into the lungs (increasing the pressure in the chest) This is good when the patient cannot do so on their own…but…

EXCESSIVE VENTILATIONS Ventilations that are excessive: Are too fast Are too forceful Cause excessive positive pressure in the chest Excessive Intrathoracic Pressure Decreases cardiac output by inhibiting blood return to the heart Increases pressure in the brain (ICP) Decreases Coronary Perfusion Pressure (CPP) and Cerebral Perfusion Pressure (CerPP) both linked to causing negative outcomes in OHCA.

HOW TO AVOID EXCESSIVE VENTILATIONS 1.Give appropriate TIDAL VOLUMES during ventilations 1.Ventilate only until you see chest rise 2.Usually half a bag squeeze on BVM 2.Ventilate at APPROPRIATE RATES 1.Avoid Excessive Compressions ( ) 1.Maintain 30:2 Compression/Ventilation Ratios 2.Going faster than 120 compressions/min increases # of breaths given over time 2.If Advanced airway is in place, ventilate 1 every 6 seconds 1.Count out the MISSISSIPPI’s (1 MISSISSIPPI, 2 MISSISSIPPI, 3 MISSISSIPPI, 4 MISSISSIPPI, 5 MISSISSIPPI, BREATHE) 3.Avoid EXCESSIVE FORCE while delivering ventilations 1.Deliver the breath over 1 second ( )

SO WRAP UP SO FAR… Teamwork helps achieve goals of High Quality “High Performance” CPR Goals include: Quality Compressions (>2 inches) Quality Rate ( ) Avoiding excessive ventilation Maximizing Chest Compression Fraction (60-80%) Minimizing all pauses, especially the longest

RETURN OF SPONTANEOUS CIRCULATION What happens when I get a pulse back? We have a protocol for that! Key is to OPTIMIZE: Adequate oxygenation Adequate ventilation Adequate perfusion

TO COOL OR NOT TO COOL, THAT IS THE QUESTION You guessed it… We have a Protocol for that too!

DOES THIS TEAMWORK THING WORK? January Study published in Circulation: Implementation of Pit Crew Approach and Cardiopulmonary Resuscitation Metrics for Out-of-Hospital Cardiac Arrest Improves Patient Survival and Neurological Outcome Salt Lake City Fire Department Study: System wide quality improvement plan integrating High Performance CPR

RESULTS PRE INTERVENTION PERIOD 8% Overall Neurologically intact Survival Of Survived to Admission 37% survived to discharge 26% were Neuro Intact POST INTERVENTION PERIOD 16% Overall Neurologically intact Survival Of Survived to Admission 50% survived to discharge 46% were Neuro Intact

IT TAKES MORE THAN JUST GOOD EMS Systems Approach: CPR performed by Lay rescue prior to EMS arrival- associated 2x as likely to survive (Hasselqvist ‑ Ax, et al., 2015) Early Recognition, Early Bystander, Early Public Access Defibrillation In other words…… THE CHAIN OF SURVIVAL

TEAM APPROACH TO RESUSCITATION How do we achieve quality CPR? TEAMWORK!!!

EFFECTIVE TEAMS: Assign team roles while en route, or at beginning of a shift; Reduces unnecessary discussion during initial assessment Creates clear communication and standards Train together We train like we fight, and we fight like we train (make training and practice a team- based evolution) Communicate Effective teamwork requires communication. Appropriate feedback and closed loop communication is key. Must be clear, concise and professional. Effective communication inhibits misunderstanding and increases collaboration

IF THIS GUY CAN’T DO IT ALONE…

NEITHER CAN THIS ONE

RESOURCES AHA Consensus Statement on Resuscitation: f AHA High Quality CPR Webpage QualityCPR/UCM_473208_High-Quality-CPR.jsp Sudden Cardiac Arrest Foundation AHA 2015 Guidelines AHA ECC Scientific Statements tsArchive/UCM_476674_ECC-Scientific-Statements-Archive.jsp

REVIEW Answer the following questions as a group. If doing this CE individually, please your answers to: Use “March 2016 CE” in subject box. You will receive an confirmation. Print this confirmation for your records, and document the CE in your PREMSS CE record book. IDPH site code # E1216

1.What is the appropriate RATE for Chest Compressions in an ADULT? 2.What is the appropriate RATE of Chest Compressions in a CHILD or INFANT? 3.What is the systems approach to resuscitation called by the American Heart Association? 4.What is included in HIGH QUALITY CPR?

5.Give 2 reasons why excessive ventilation is bad 6.Identify the roles in the resuscitation team 7.What is the correct compression/ventilation ratio in an Adult? Child? and Infant?

8.Define Compression Fraction 9.What is the targeted CF in an arrest? 10.Define the role pauses play in arrest, and name 3 causes for pauses