1. Science Driving the Future of Basic Life Support Paris Hotel and Casino  Las Vegas, Nevada Presented by: Dana Edelson, MD, MS, FAHA, FHM Medical Director of Rescue Care and Resiliency University of Chicago Medicine

2. Presenter Disclosure Information Dana Edelson Science Driving the Future of Basic Life Support FINANCIAL DISCLOSURE:  Employed by the University of Chicago  Grants from the National Institutes of Health, Philips Healthcare, American Heart Association, Laerdal Medical  Ownership interest in Quant HC and intellectual property for analytics related to predicting in-hospital cardiac arrest UNLABELED/UNAPPROVED USES DISCLOSURE:  None

3. History of Resuscitation Liss. Ann Emerg Med 1986; 15:65-72. 3QCPR & IHCA | 15001600 19001800 1700 Bellows Method (1500s) Rolling Method (1856) Side to side compression (1831) Barrel Method (1700s) Prone compression (1903)

4. Development of closed chest cardiac massage (1960) 4QCPR & IHCA |

5. Introduction of CPR sensing defibrillators (2005) QCPR & IHCA |5

6. Resuscitation Eras 6QCPR & IHCA | Early resuscitation 1740-1960 Qualitative CPR 1960-2005 Quantitative CPR 2005-present Mouth to mouth ventilation endorsed in Europe Early methods of chest compression taught Closed chest cardiac massage published AHA holds first CPR course CPR measuring defibrillators available IHCA and OHCA CPR quality published

7. Baseline CPR Quality 7QCPR & IHCA | January 19, 2005

8. Abella, JAMA, 2005 Baseline CPR quality by trained rescuers 8QCPR & IHCA |

9. Previously by Kramer-Johanson J, 2006; Edelson DP, 2006; Stiell, 2012 Vadeboncoeur, Resuscitation, 2014 Chest compression: deeper seems better yet again 9QCPR & IHCA | Mean Compression Depth, mm

10. 1.A decrease in rate (Vadeboncoeur, 2014) 2.An increase in leaning (Robertson-Dick, 2010) Caution: an increase in depth often comes with 10QCPR & IHCA |

11. Idris, Circulation, 2012 Fast but not too fast… 11QCPR & IHCA |

12. Pauses in chest compression are bad 12QCPR & IHCA | Pre-Shock Pause, Seconds Shock Success, Percent n=17n=8n=10n=18 -Edelson, 2006; Rea, 2006; Sell, 2010; Christensen, 2009; Cheskes, 2013

13. Worsen hemodynamics Associated with poor outcomes Clinical data sparse –Aufderheide, 2004 –Niles, 2011 Hyperventilation and leaning are detrimental in animals 13QCPR & IHCA |

14. Updates on feedback, debriefing and mechanical CPR for improving CPR quality and patient outcomes Now that you can measure… 14QCPR & IHCA |

15. Impact of feedback on compression depth Abella, Resus, 2007 15QCPR & IHCA | Hostler, BMJ, 2011 IHCA OHCA

16. Impact of feedback on compression rate Abella, Resus, 2007 16QCPR & IHCA | Hostler, BMJ, 2011 IHCA OHCA

17. Feedback + situational training Pre- intervention Post- intervention P-value Compression depth 44 mm54 mm<0.05 Compression rate 126/min105/min<0.05 Compression fraction 0.660.84<0.05 Ventilation rate12/min10/min<0.05 17QCPR & IHCA | Bobrow, Ann Emerg Med, 2013

18. Debriefing 18QCPR & IHCA |

19. 19QCPR & IHCA |

20. Results: CPR at goal over time Abella, Resuscitaton, 2007 Edelson, Arch Int Med, 2008 20QCPR & IHCA | Feedback + debriefing

21. Results: Return of circulation Edelson, Arch Int Med, 2008 21QCPR & IHCA | p=0.03

22. Pediatric Debriefing Data Wolfe, Crit Care Med, 2014 22QCPR & IHCA |

23. Pediatric Debriefing Outcomes 23QCPR & IHCA | Wolfe, Crit Care Med, 2014

24. Integrated Automated Load Band Distributing CPR 24QCPR & IHCA |

25. June 14, 2006 Hallstrom et al. Multicenter, randomized Early discontinuation ↓ survival to discharge: 9.9%  5.8% (p=0.06) ↓ neurologically intact survival: 7.5%  3.1% (p=0.006) Ong et al. Richmond, VA. historical control ↑ROSC: 20.2%  34.5%* ↑Survival to discharge: 2.9%  9.7%* *p<0.05 25QCPR & IHCA |

26. 26QCPR & IHCA |

27. Circ Trial Outcomes – no difference Compression fraction 0.80 in both groups!!! 27QCPR & IHCA |

28. 28QCPR & IHCA |

29. High-quality CPR should be recognized as the foundation on which all other resuscitative efforts are built Continually adjust resuscitative efforts based on the patient’s physiological response Capture CPR performance data in every cardiac arrest and use an ongoing CPR CQI program to optimize future resuscitative efforts Final Consensus Recommendations Meaney et al, Circulation, 2013 29QCPR & IHCA |

30. Target CPR performance metrics: –CCF >80% –Compression rate of 100–120/min –Compression depth of ≥50 mm in adults with no residual leaning (At least one third the anterior-posterior dimension of the chest in infants and children) –Avoid excessive ventilation (Only minimal chest rise and a rate of <12 breaths/min) Recommendations (cont) 30QCPR & IHCA | Meaney et al, Circulation, 2013

31.  New data supports import of high quality CPR  Compression rate recommendations should likely include an upper limit  Data in support of real-time feedback is strengthened, though still no outcome benefit  Data in support of debriefing now includes a possible pediatric survival benefit  High quality manual CPR is equivalent to integrated automatic load-distributing band CPR Conclusions 31QCPR & IHCA |

32. Thank you 32QCPR & IHCA |

33. Acknowledgements Ben Abella, MD, MPhil Lance Becker, MD Trevor Yuen Brian Robertson-Dick, MD Meredith Borak, RN, MSN Matt Churpek, MD, MPH, PhD Frank Zadravecz, MPH Nicole Twu, MS

34. Questions?