1. CPR: Push 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

2. Disclosures I am on the Physio-Control Speakers Bureau I don’t know how to play golf or ski

4. www.mikemcevoy.com

5. Outline CPR 2010: that was then, this is now… Show me the money: is there proof? What matters? Why measure? How to assess quality CPR Unique hospital issues Future solutions

6. Adult Chain of Survival: 2010 1.Immediate recognition and activation of emergency response system 2.Early CPR with emphasis on chest compressions 3.Rapid defibrillation 4.Effective ALS 5.Integrated post-cardiac arrest care

7. 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

8. So, What Matters in CPR? And how should we assess effectiveness?

9. Chest Compressions 2010 > 50 mm ( > 2”) At least 100 per minute 2005 38 – 51 mm (1.5 – 2”) 100 per minute Most Common Errors: 1.Too slow 2.Not deep enough 3.Prolonged interruptions 4.Leaning

10. 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

11. CPR Rate vs. ROSC p < 0.0083 Abella et al. Circulation. 2005;111:428-434

12. Probability of ROSC Stiell et al. Crit Care Med 2012; 40:1192-1198

13. One Day Survival Stiell et al. Crit Care Med 2012; 40:1192-1198

14. Survival to Discharge Stiell et al. Crit Care Med 2012; 40:1192-1198

15. 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

16. Waveform Capnography Attaches to ET tube, measures CO 2

17. Oxygen  Lungs  alveoli  blood Muscles + Organs Oxygen Cells Oxygen + Glucos e ENERGY CO 2 Blood Lungs CO 2 Breath CO 2 Physiology of Metabolism

18. SpO 2 versus EtCO 2

19. Oxygenation and Ventilation Oxygenation (Pulse Ox) –O 2 for metabolism –SpO 2 measures % of O 2 in RBCs –Reflects changes in oxygenation within 5 minutes Ventilation (Capnography) –CO 2 from metabolism –EtCO 2 measures exhaled CO 2 at point of exit –Reflects changes in ventilation within 10 seconds

20. Measuring Exhaled CO 2 Colorimetric Capnometry Capnography

21. Measuring Exhaled CO 2 Colorimetric Capnometry Capnography

22. Measuring Exhaled CO 2 Colorimetric Capnometry Capnography

23. Capnography Waveforms 45 0 0 Hypoventilation Normal Hyperventilation 45 0

24. 98 Sp0 2 What about the Pulse Ox?

25. Carbon Dioxide (CO 2 ) Production

26. What If…

27. But, with High-Quality CPR…

28. Meet Howard Snitzer 54-years old, collapsed Jan 5, 2011 outside Don’s 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

29. Why Not Quit? Thrombectomy, stent to LAD 10 days inpatient “The capnography told us not to give up” EtCO 2 averaged 35 (range 32 – 37)

30. So What’s the Goal During CPR? Try to maintain a minimum EtCO 2 of 10 Push HARD (> 2”) FAST (at least 100) Change rescuer Every 2 minutes

31. Guidelines 2010 Continuous quantitative waveform capnography recommended for intubated patients throughout peri- arrest period. In adults: 1.Confirm ETT placement 2.Monitor CPR quality 3.Detect ROSC with EtCO 2 values

32. Guidelines 2005 EtCO 2 recommended to confirm ET tube placement

33. 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. 1997;337(5):301-306. EtCO 2 detects ROSC 90 pre-hospital intubated arrest patients 16 survivors 13 survivors: rapid rise in exhaled CO 2 was the earliest indicator of ROSC Before pulse or blood pressure were palpable

34. Capnography = Results, not process

35. Guidelines 2010: Evidence Capnography Classes & Levels of Evidence: 1.Confirm ETT placement: Class I, LOE A 2.Monitor CPR quality: Class IIb, LOE C 3.Detect ROSC with EtCO 2 : Class IIa, LOE B

36. 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: don’t do it

37. Levels of Evidence: Proof A – A whole lotta proof: best! B – Some proof: better than nothing C – No proof: but some like the idea

38. Guidelines 2010: Evidence Capnography Classes & Levels of Evidence: 1.Confirm ETT placement: Class I, LOE A Just do it, best proof 2.Monitor CPR quality: Class IIb, LOE C Think first, some like the idea 3.Detect ROSC with EtCO 2 : Class IIa, LOE B Do it, better than nothin’

39. CPR is Complicated!

40. Hospital Issues: 1.Bed Height –Optimal = bed at knee level of person administering chest compressions Cho et al, Emerg Med J. 2009;26:807-810 2.Air Mattresses –No need to deflate mattress for CPR Perkins et al, Inten Care Med. 2003;29:2330-2335 3.Backboards –No evidence of benefit with backboard Perkins et al, Inten Care Med. 2003;29:2330-2335

41. What About Quality? In-Hospital Arrests, Dec 2004 – Dec 2005

42. Audiovisual CPR Feedback Incorporated into monitor/defibrillator Real time Accelerometer-based

43. Handheld Feedback Device Handheld accelerometer-based audiovisual device

44. Generation of Feedback

45. Post Code Reviews (Code Stat ™)

46. EMS Feedback = ROSC FDNY uses audio-visual feedback Deactivated audio feedback for 1 week ROSC  20% NY State EMS Council Report Jan 2012

47. But Hospitals ≠ EMS How effective are feedback systems?

48. We have a problem:

49. Accelerometer CPR Depth Perkins et al. Resuscitation 2009;80:79-82

50. 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 2009;80:79-82

51. The Solution: Directly measure the true compression depth.

52. Two end points Direct measurement of distance (magnetic) Discrimination of X, Y, Z Accommodation of Roll, Pitch and Yaw Triaxial Field Induction 1 2

53. TFI versus ACC Banville et al. Circulation 2011; 124:A217

54. 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: EtCO 2 and ACC –CO 2 delayed –ACC inaccurate Future: TFI –Very promising