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CPR in the ED: R U Ok? Mike McEvoy, PhD, RN, CCRN, NRP Resuscitation Committee Chair and Sr. Staff Nurse CTICU – Albany Medical Center EMS Coordinator – Saratoga County, NY EMS Editor – Fire Engineering magazine 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 assess quality CPR Unique hospital issues 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 on chest 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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Let’s Get One Thing Straight: Where do most cardiac arrests occur? ~ 175,000 per year out of hospital –ROC data (Nichol et al, JAMA 2008) ~ 200,000 per year in hospital –2003-2007 GWTG-R data Merchant, Yang, Becker, Berg, Nadkarni, Nichol, Carr, Mitra, Bradley, Abella, Groeneveld, CCM 2011 Attention American Heart Association: You need to focus more effort on IHCA
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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
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Chest Compressions ROC: survival associated with depth Abella et al: 100-120/min = survival Recommendations are LOE 4 & 5 (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 < 0.0083 Abella et al. Circulation. 2005;111:428-434
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Probability of ROSC Stiell et al. Crit Care Med 2012; 40:1192-1198
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One Day Survival Stiell et al. Crit Care Med 2012; 40:1192-1198
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Survival to Discharge Stiell et al. Crit Care Med 2012; 40:1192-1198
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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 U.S. TJC future standard
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Waveform Capnography Attaches to ET tube, measures CO 2
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Oxygen Lungs alveoli blood Muscles + Organs Oxygen Cells Oxygen + Glucos e ENERGY CO 2 Blood Lungs CO 2 Breath CO 2 Physiology of Metabolism
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Measuring Exhaled CO 2 Colorimetric Capnometry Capnography
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Measuring Exhaled CO 2 Colorimetric Capnometry Capnography
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Measuring Exhaled CO 2 Colorimetric Capnometry Capnography
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Carbon Dioxide (CO 2 ) 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 Don’s Foods in Goodhue, MN (pop. 900) 2 dozen 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” EtCO 2 averaged 35 (range 32 – 37)
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So What’s the Goal During CPR? Try to maintain a minimum EtCO 2 of 10 mmHg (1.4 kPa) Push HARD (> 2” or 5 cm) 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: 1.Confirm ETT placement 2.Monitor CPR quality 3.Detect ROSC with EtCO 2 values
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Guidelines 2005 EtCO 2 recommended to confirm ET tube placement
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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
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Capnography = Results, not process
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CPR is Complicated!
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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
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AHA Guidelines - 2013 Pre, Intra, Post arrest recommendations: 1.Real time feedback at the point of care 2.Shock early, don’t interrupt CPR, avoid hyperventilation, optimize depth 3.BENCHMARK
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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 2009;80:79-82
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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 2009;80:79-82
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CPR on Mattress
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CPR with a Backboard
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The Solution: Directly measure the true compression depth.
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Two end points Direct measurement of distance (magnetic) Discrimination of X, Y, Z Triaxial Field Induction 1 2
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TFI versus ACC Banville et al. Circulation 2011; 124:A217
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Where Is TFI?
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On the Code Cart!
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Back Pad Under Patient
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Compress Chest Pad
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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 hospital requirement Current tools: EtCO 2, ACC, TFI –CO 2 delayed –ACC inaccurate –TFI - Very promising!
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