Bringing Science to the Pit Crew: High-Functioning EMS CPR Teams

1. Bringing Science to the Pit Crew:High-Functioning EMS CPR Teams

2. Bringing Science to the Pit Crew:High-Functioning EMS CPR Teams “The Science”

3. Cardiac arrest is the ultimate EMS disease! arrest CPR defibrillation % Surviving ROSC hospital discharge Time

4. CPR is over 50 years old, but recent changes have shown increases in survival A B A. Peter Safar, 1950s B. Early symposium on CPR 1961

5. Survival is related to arterial pressures generated by chest compressions 35 30 25 20 15 10 5 0 Not the pH Not the oxygen content It’s all about Coronary Perfusion Pressure ! Coronary Perfusion Pressure (mm Hg) 24-hour Survivors Could Not Resuscitate Resuscitated But Expired Kern, Ewy, Voorhees, Babbs, Tacker Resuscitation 1988; 16: 241-250 Paradis et al. JAMA 1990; 263:1106

6. Chest compression rates 300 250 200 150 100 50 0 n=1626 segments Number of 30 sec segments 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 R>120 Chest compression rate (min-1) Abella et al, 2005

7. Survival better with compression rate of 100 – 120 compressions/minute Mean rate, ROSC group 90 ± 17 * 210 180 150 120 90 60 30 0 p=0.003 Mean rate, no ROSC group 79 ± 18 * No ROSC ROSC Number of 30 sec segments 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 >120 Chest compression rate (min-1) Abella et al, 2005

8. Survival better with compressions >2 inches deep 40 32 24 16 8 0 2 inches vs 1.5 inches Survival: 100% 15% CPP, mm Hg 1 2 3 CPR duration, min ICCM, 2005

9. Shock success by compression depth p=0.02 Shock success, percent n=13 n=14 n=5 n=10 Compression depth, inches Edelson et al, 2006

10. 2005 AHA Guidelines

11. 2010 AHA Guidelines EVEN EVEN EVEN

12. How Does CPR Cause Blood Flow?Thoracic Pump +

13. Ensure Total Chest Recoil with:1) Lifting palm during compressionsor2) Using feedback device +

14. Allow Complete Recoil

15. Allow Complete RecoilLift Palms During Compressions

16. CPR sensing and recording defibrillator Examples: Devices providing real-time feedback are available from several manufacturers

17. Patients can be hyperventilated to DEATH! 16 seconds v v v v v v v v v v mean ventilation rate: 30 ± 3.2 first group: 37 ± 4 after retraining: 22 ± 3 Aufderheide et al, 2004

18. 160 5 sec 120 mmHg 80 40 Time (sec) Single rescuer performing 30:2 with realistic 16 sec. interruption of chest compressions for MTM ventilations No Cerebral Perfusion Cerebral Perfusion Pressures CoronaryPerfusion Pressures 0 EwyGA, Zuercher, M. Hilwig, R.W. et al Circulation2007;116:2525

19. 160 5 sec 120 mmHg 80 40 Time (sec) Perfusion with continuous compressions Single rescuer performing continuous chest compressions Continuous Cerebral Perfusion Pressures CoronaryPerfusion Pressures 0 Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation2007;116:2525

20. Defib first CPR (90 sec) first, then defib 42 months 36 months CPR before defibrillation may increase survival (when CA not witnessed by EMS) Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation 24% (155/639) 30% (142/478) p=0.04 Cobb et al, 1999

21. CPR first may improve survival: RCT 0.5 0.4 0.3 0.2 0.1 0 CPR first Standard care probability of survival p=0.006 0 2 4 6 8 10 12 14 time from collapse, min Wik et al, 2003

22. Chest compression pauses before shocks 4:55 5:00 5:05 5:10 Compressions ECG Pause before shock

23. Shock success by pre-shock pauses 100 p=0.003 90% 80 60 64% Shock success, percent 55% 40 20 10% 0 ≤10.3 (n=10) 10.5-13.9 (n=11) 14.4-30.4 (n=11) ≥33.2 (n=10) Pre-shock pause, seconds Edelson et al, 2006

24. CPR renaissance: measuring CPR matters Valenzuela et al, Circ 2005 Wik et al, JAMA 2005 Abella et al, JAMA 2005 Aufderheide et al,Circ 2004

25. Key “take home” points • Cardiac arrest is not hopeless! • CPR quality has biggest impact • Adequate chest compression rate (100-120/min) • Maximize chest compression depth (>2 in.) • Allow for complete chest recoil • Minimize pauses !! • Minimize ventilations (8-10 bpm) • Use capnography & debriefing, consider CPR feedback tools • Ensure access to hypothermia and cardiac catheterization

26. 3-Phase Time-Sensitive Model of Cardiac Arrest Due to VF The Electrical Phase (0 to ~5 minutes) Early defibrillation life-saving The Circulatory Phase (~5 to ~10 minutes) Intubation and immediate AED can be detrimental Compressions first may be life saving The Metabolic Phase (~>10 minutes) Survival decreased Science searching for more successful treatments Weisfeldt ML, Becker LB. JAMA 2002;288:3035

27. Dispatcher-assisted hands-only CPR 2010 Bystander contacted 9-1-1 standard CPR (n=960) chest compression alone (n=981) 11.5% 14.4% (OR 2.9) Survival to DC

28. CPR (2010) emphasizes: Circulation Airway Breathing CCR (Cardiocerebral Resuscitation) emphasizes: Circulation (uninterrupted compressions) Deemphasizes ventilation

29. “Tucson” version (2003) Cardiocerebral Resuscitation (Intubation delayed; Bag Valve Mask ventilation) 200 chest compressions 200 chest compressions 200 chest compressions 200 chest compressions EMS arrival Analysis Analysis Analysis No intubation: Bag Valve Mask ventilation BeginIV 1 mg EPINEPHrine every 3 to 5 minutes Follow ACLS Guidelines? • If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis and shock if indicated

30. Survival after Bystander CPR for OHCA in Arizona (2005 to 2010) Compression Only CPR Advocated and Taught A. B. All OHCA Witnessed/Shockable 35% 30% 25% 20% 15% 10% 5% 0% 33.7% AOR 1.6 (95% CI, 1.08-2.35) P < 0.001 Survival to Hospital Discharge 17.7% 13.3% 7.8% Std-CPR COCPR Std-CPR COCPR Bobrow, et al. JAMA 2010:304:1447-1454

31. Neurological Intact Survival from CCRWitnessed collapse and shockable rhythm 50% 40% 30% 20% 10% 0% 39/102 75/192 35/89 34/136 Neurologically Normal Survival to Hospital Discharge 39% 38% 38% Rock and Walworth Arizona K.C. MO Annals Emergency Med2008 Annals Emergency Med2009 Circulation2009

32. Gasping Should Not Distract from Recognizing Patient in Cardiac Arrest EMD recordings of 445 witnessed cardiac arrests Non-witnessed arrest: 16% gasping Witnessed arrest: 55% gasping (p <0.001) Example of Gasping (Bondi Beach, YouTube) Clark etal. Ann Emerg Med 1992;21:1464

33. Medications proven to improve outcome in cardiac arrest?

34. The priority is quality compressions Reflected in the poor impact of ACLS meds: 2009 Randomized trial of EPINEPHrine versus no EPINEPHrine For EMS treated cardiac arrest  NO BENEFIT IN SURVIVAL TO DISCHARGE FROM HOSPITAL!

35. Bringing Science to the Pit Crew:High-Functioning EMS CPR Teams “The Pit Crew Approach”

36. AHA 2010 Guidelines • C-A-B • Uninterupted chest compressions • Waveform capnography • Deemphasized: • Intubation • Drugs • Mechanical CPR

37. Statewide Protocols 331A/ 3031AGeneral Cardiac Arrest - Adult • Don’t be fooled by agonal respirations • Cycles of 200 uninterrupted compressions • Early defib if good bystander CPR or EMS witnessed arrest

38. 331A • 4 cycles of 200 compressions/ defib • Compressions cause passive ventilation • Medical director sets airway/ ventilation options

39. 331A • After 4 cycles of 200 uninterrupted compressions, add ventilations at 15:1 • Indications for possible BLS field termination of CPR • Arrest not witnessed by EMS, AND • No ROSC/pulse prior to transport, AND • No AED shock delivered prior to transport

40. 3031A • EPINEPHrine every 3-5 minutes • Antidysrhythmic if 2nd shock needed • Medical director sets airway/ventilation options for agency • Monitor capnography • Avoid intubation during initial cycles of compressions

41. 3031A

42. 3031A • Treat reversible causes • Pneumothorax • Hypovolemia • Appropriate medication • Antidysrhythmic • Mg for torsades (rare) • Calcium/bicarbonate in dialysis • Avoid inappropriate care • Naloxone • Glucose testing

43. High-Functioning CPR AgencyThe Pit Crew Team

44. Equipment organized to be efficient

45. Team member roles pre-assigned

46. Frequent practice/ simulation

47. Let’s Examine a NASCAR Pit Crew

48. Team Leader AttributesNREMT • Creates, implements and revises an action plan • Communicates accurately and concisely while listening and encouraging feedback • Receives, processes, verifies, and prioritizes information • Reconciles incongruent information • Demonstrates confidence, compassion, maturity, (respect for team members), and command presence • Takes charge • Maintains accountability for team’s actions/outcomes • Assesses situation and resources and modifies accordingly

49. Team Member AttributesNREMT • Demonstrates followership – is receptive to leadership • Maintains situational awareness • Utilizes appreciative inquiry • Avoids freelance activity • Uses closed-loop communication • Reports progress on tasks • Performs tasks accurately and in a timely manner • Advocates for safety and is safety conscious at all times • Leaves ego/rank at the door

50. Pit Crew ApproachCompressions are Priority • Continuous chest compressions with minimal interruption are key • USE any available feedback device/ metronome • Alternate compressions between providers across patient’s chest (e.g. 100 each) • Chest compressions should continue when charging an AED or manual defibrillator • Chest compressions should resume immediately after any shock Goal = keep interruptions for rhythm check/defibrillation < 10 seconds Goal = NO interruption for airway device insertion