CPR: Are You a Machine or Do You Need One?
Outline Mechanical CPR update Are you a machine? Measuring performance ED/hospital challenges When mechanical CPR could make a difference
New Guidelines The evidence does not demonstrate a benefit with the use of mechanical piston devices for chest compressions versus manual chest compressions in patients with cardiac arrest. Manual chest compressions remain the standard of care for the treatment of cardiac arrest. However, such a device may be a reasonable alternative to conventional CPR in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous for the provider (eg, limited rescuers available, prolonged CPR, CPR during hypothermic cardiac arrest, CPR in a moving ambulance, CPR in the angiography suite, CPR during preparation for ECPR).
Key Points 1. Mechanical vs Manual CPR No difference 2. Manual CC remain standard of care 3. Mechanical CC may be an alternative to manual CC in specific settings Where delivery of CC challenging or dangerous 4. Provided rescuers limit interruptions
Specific Situations? Limited rescuers Prolonged CPR Moving ambulance (or helicopter) Cath lab ICU, ED Preparation for ECPR Others?
What is High Quality CPR? Rate 100 120/min Depth 2 2.4 (5 6 cm) Full recoil Ventilation 10/min (q 6 secs) Few interruptions
Rate vs. ROSC 96-139 87-95 72-87 ROSC No ROSC 40-72 p < 0.0083 0% 20% 40% 60% 80% Abella et al. Circulation. 2005;111:428-434
What s the optimal rate? 100-120 95% CI Circulation (2012) Jun 19;125(24):3004-12
Depth: Probability of ROSC Stiell et al. Crit Care Med 2012; 40:1192-1198
Depth: One Day Survival Stiell et al. Crit Care Med 2012; 40:1192-1198
Depth: Survival to Discharge Stiell et al. Crit Care Med 2012; 40:1192-1198
Recoil and Leaning
Ventilation Optimal rate? AHA says 10/min Research: 8 10 Practice: way too fast Lyfetimer.com
CCF Chest Compression Fraction = time spent doing compressions > 80% Christenson et al. Circulation (2009)
How is your CPR? (Are you a machine?) Cath lab cardiac arrest Debriefing: quality of CPR good
CPR Dashboard Compression count = 492 Pauses over 10 seconds = 3 Longest pause = 0:15
CPR Report Card Hospital issues: Chest Compression Fraction (CCF) Rate Depth Recoil Ventilation
Who does better CPR? 36 RNs (26 females, 20 males) Males: 80% effective compressions Females: 40% effective compressions Jones & Lee; AJCC 2008 17(5)
Probably not Is it really gender? Hasegawa et al. J Physiological Anthropology 2014, 33:16
% Passing Skills Test CPR Skill Decay 100% 90% 80% 70% 60% 50% 40% 30% 34% 27% 20% 10% 0% 10% 3 months 6 months 12 month Average Skill Loss www.heart.org/heartorg/general/resuscitation-quality-improvement_ucm_459324_subhomepage.jsp
How do you measure rate?
Download your monitor/defib
Metronome? Real time coaching Good data to support metronome use in both training and actual CPR events Yeung, Joyce et al. The use of CPR feedback/prompt devices during training and CPR performance: A systematic review. Resuscitation. 80 (7): 743-751
How do you measure CCF?
Chest Compression Fraction If > 80% associated with survival, then: Minimize interruptions Reduce perishock pauses ICU code:
How do you measure depth?
We have a problem:
Accelerometer CPR Depth Perkins et al. Resuscitation 2009;80:79-82
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
CPR on Mattress
CPR with a Backboard
The Solution: Directly measure the true compression depth.
TFI Triaxial Field Induction TrueCPR
Back Pad Under Patient
Compress Chest Pad
Triaxial Field Induction (TFI) Completely Different than Accelerometers 1 2 Base plate creates 3-dimensional magnetic fields Top piece senses field Calculates true Anterior/Posterior depth Does not require exact alignment
TrueCPR Coaching Device Metronome Depth dial Rate Event timer
TrueCPR Summary Report Green: Target depth and rate zones Yellow: Pauses
1. Bed Height Hospital Issues: Optimal = bed at knee level of person administering chest compressions 2. Air Mattresses Cho et al, Emerg Med J. 2009;26:807-810 No need to deflate mattress for CPR 3. Backboards Perkins et al, Inten Care Med. 2003;29:2330-2335 No evidence of benefit with backboard Perkins et al, Inten Care Med. 2003;29:2330-2335
CPR is Complicated!
Mechanical piston CPR
Multiple Studies Generally equivalent in outcomes when compared to manual CPR
So when might they help? 1. Provider mix 2. Long resuscitations a. Drug overdoses b. Hypothermia c. Protracted arrhythmias d. Bridge to cath lab e. Bridge to ECPR 3. Environment (ICU, cath lab, ED, helicopter, moving ambulances)
Woman vs. Machine? Simulated CPA in pigs; coronary blood flow 1 CPP: 20-25 mmhg LUCAS vs. 5-10 mmhg manual EtCO 2 : 25.5 mmhg LUCAS vs. 16.5 mmhg manual EtCO 2 measurement in humans 2 EtCO 2 values higher in LUCAS patients 126 OHCA patients Average 24.5 mmhg vs. 20.4 mmhg 1.Liao Q, et al. Manual versus mechanical cardiopulmonary resuscitation. An experimental study in pigs. BMC Cardiovasc Dis. 2010;10:53 2.Axelsson C, Karlsson T, Axdelsson A, et al. Mechanical active compression decompression cardiopulmonary resuscitation (ACD-CPR) versus manual CPR according to pressure of end tidal carbon dioxide (PETCO 2 ) during CPR in out-of-hospital cardiac arrest (OHCA). Resus. 2009:80(10):1099-1103.
Measures need to evolve Pneumonia Antibiotics fever WBCs, etc Cardiac Arrest CPR CPR Rate, depth, etc.
Measures need to evolve Pneumonia Antibiotics Was fever ABX WBCs, etc given? Cardiac Arrest CPR CPR
Waveform Capnography Attaches to ET tube, measures CO 2
Capnography = Results, not process Rate 100 120/min Depth 2 2.4 (5 6 cm) Full recoil Ventilation 10/min (q 6 secs) Few interruptions
You need a few machines: Metronome Depth measure Recoil measure Ventilation timer CCF or pause timer Or
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