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 Survival is 18-20% There is tremendous variability among hospitals Get with the Guidelines 135,896 – 20% with Ventricular fibrillation or Ventricular tachycardia – 64% occur in an ICU Median Survival Varies – 8.3% at the lowest Decile – 31.4 at the highest JAHA. 2014;3:e000400

Clinical FeatureOdds RatioP VT/VF3.14< PEA Etiology Toxicologic 2.36 ICU1.60< Monitored1.72< Comorbid Hepatic insufficiency 0.54< Comorbid Cancer0.50< Arrest time at night 0.74< Arrest time Weekend 0.86< JAHA. 2014;3:e000400

What seems to work? Performing ACLS correctly is associated with an improvement in outcome 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

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:

Time course of VF

Circulation. 2005;111: and e294

J Cardiovascular Magnetic Resonance. 2011;13:17 Hypothermia during VT/VF

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:S

How Fast Rate 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:S

Circulation. 2005;

Circulation. 2012;125: ROC consortium (9 sites) OHCA in which monitors/defib measured chest compression rates 3098 cases analyzed

Circulation. 2012;125:

Compression rate vs Compressions Delivered

Circulation Qual Outcomes.2013;6:

Compression Depth

Resuscitation. 2005;64:

Circulation Qual Outcomes.2013;6:

Recoil Matters…

Resuscitation. 2006;71:

Resuscitation. 2006;64:

Circulation Qual Outcomes.2013;6:

Resuscitation, 2007;73:54-61

Resuscitation. 2009;80:

Non-Shockable Rhythms

Circulation. 2012;125:

Chest Compressions and Defibrillation

Resuscitation. 2006;71:

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:

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