efccna congress march 2011 01/session...conclusion there is one clinical observational study...

Chest compression ONLY CPR: Is it more effective?

Marios C. Georgiou CCRN, BSc, MSc CyRC ChairmanERC Executive CommitteeILCOR Worksheet AuthorERC Guidelines Writing GroupNicosia General Hospital

EfCCNa Congress March 2011

OverviewIntroductionStudies for CC ONY CPRStudies against or forconventional CPR

Is there is any consensus ?Guidelines

© European Resuscitation Council

ER

C

Guid

elin

es

2010

*CPR following cardiac arrest of cardiac aetiology (36 months)

Böttiger BW et al., Heart 82:674-679, 1999

Discharge 1 year

Brain / heart

damage

Outcome After Cardiac Arrest (CA)

in Heidelberg, Germany


ER

C

Guid

elin

es

2010

*CPR following cardiac arrest of cardiac aetiology (36 months)

Böttiger BW et al., Heart 82:674-679, 1999

Discharge 1 year

Brain / heart

damage

Outcome After Cardiac Arrest (CA)

in Heidelberg, Germany

350,000 unsuccessful

CPR-attempts / year in

the EU

Sudden cardiac Death (SCD)

The problem

Survival of OOHCA 4% - 33% depend on local chain of survival

Good EMS in Western societies survival <30%

Meta analysis 17 studies: Bystander CPR: increases survival 4-5 times.

Cummins et al, Circulation 1991;83:1832-47

Chain of survival

Cummins et al Circulation 1991; 83:1832-47

ERC guidelines 2005 / 2010

Improving circulation

30:2 compression to ventilation ratio

The shift from 15:2 to 30:2 compression to ventilation ratio doubles the common carotid blood flow and increases by 25% the cardiac output without any compromise in oxygenation and acid-base balance

Yannopoulos et al Critical care Med 2006; 34:1444-9

Ventilation

A simple change in the compression to ventilation ratio from 15:2 to 15:1 resulted in an increase in diastolic aortic pressure and higher cerebral perfusion pressure in pigs

Yannopoulos et al Critical care Med 2006; 34:1444-9

Chest compression only CPR

ERC guidelines 2005


ER

C

Guid

elin

es

2010

International Consensus

Conference on ECC and CPR

Science + Treatment

Recommendations (4 years)

277 questions / Worksheets

313 delegates / 30 countries

Treatment recommendations”,

evidence-based

new ERC, AHA Guidelines

online 18. October 2010

www.Iilcor.org, www.erc.edu

C2010 – The Process

ILCOR Worksheet Question

"In adult patients suffering from a cardiac arrest (P) does the provision of chest compressions (without ventilation) from bystanders, both trained and untrained, (I) compared with chest compressions plus mouth-to-mouth breathing (C) improve survival to hospital discharge (O)?".

Number of studies / articles for

further analysis.

47 related publications:

16 reviews/editorial/letters; 15 clinical trials/observational studies or case series; 13 animal studies; 7 manikin trials and 2 computer model.

33 included for further analysis.

Summary of evidence

Supporting Clinical Question

GoodHigdon – 2006 /M

Turner-2002 /E (for 0-2 min)

Wollard-2003 /M (telephone)

Heidrenreich-2006 /M (<3min)

Hallstrom-2000 /C (telephone

CPR)

Fair Nagao-2007 /E

Virkkunen-

2006 /E

Ewy-2007

Kern-2002

Kellum-2006 /D (CCR protocol)

Poor

1 2 3 4 5

Level of evidence

Dioszegy C, (2010)

Evidence Neutral to Clinical question

Good

Ong-2008 / C

Iwami-2007 /D (<15

min)

Olasveengen-2008 /C

Berg-1997

Berg-1995

Kern-1998

Turner-2002 /S (for 3-4 min)

Heidrenreich-2006 /M

(>3min)

Fair Van Hoeyweghen-1993 /B

Waalewijn-2001 /C

Nagao-2007 /E (non

VF/VT)

Bohm-2007 /E

Berg-1993

Poor

Deakin-2007/E

1 2 3 4 5

Level of evidence

Dioszegy C, (2010)

Evidence Opposing Clinical QuestionGood

Iwami-2007

/D(>15min)

Abe-2009 /D

Dorph-2004

Berg-2000(asphyxia)

Idris-1994

Turner-2002 / S (for >4

min)

Markstaller-2008

Cavus-2008

Odegaard-2006 / M

(quality)

Kill-2009

Yeh-2009

Trowbridge-2009 / M

(quality)

Fair Holmberg-2001/C

PoorSwor-2006 /E (attitude)

1 2 3 4 5

Level of evidence

Dioszegy C, (2010)


Facts:

Although bystander CPR can substantially improve outcomes from cardiac arrest, it typically is provided to <25% of cardiac arrest victims

This low rate of bystander CPR can be explained by:

Fear of causing harm

Difficulty in learning and performing this complex psychomotor task

Aversion to mouth to mouth rescue breathing

Cultural factors


Berg et al Circulation 1993;88:1907-15

Difference in CPR ratio / affect intra aortic pressure and blood gases.

Turner (2002) Resuscitation 52; 55-62

ABC – CPR 15:2 Better CPP with CCC - CPR

Karl, B Kern Circulation 2002; 105; 645-649

Chest compression only CPR(Cardio-cerebral resuscitation)

73%70%

7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

CCC-CPR Ideal-CPR No-CPR

CCC-CPR

Ideal-CPR

No-CPR

24h neurologically normal Survival of simulated out-of-hospital cardiac arrest in 6 studies

Ewy et al Circulation 2005; 111:2134-42

70%

42%

0%

10%

20%

30%

40%

50%

60%

70%

80%

CCC-CPR Ideal-CPR

30:2

CCC-CPR

Ideal-CPR 30:2

24h neurologically normal Survival of 64 animals after 12 Min VF arrestBystander resuscitation with 30:2 Vs CC Only

Ewy et al Circulation 2007; 116;2525-2530

CCR Protocol: (Paramedics) 200 CC non stop. Oropharyngeal airway and Ο2. minimum interruptions for rhythm and pulse checks. In case of witnessed arrest: rescue breaths and intubation delayed until ROSC or until 3 Χ 200 CC.

Comparison with 15:2 from 2001 – 2003

CCR applied beginning 2004 - 2005 in 33 witnessed cardiac arrests.

15%

48%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

CPR - 15:2 CCR Protocol

CPR - 15:2

CCR Protocol

Neurologically Intact Survival of OOHCA (witnessed) 2001 – 2003 15:2 x (92) Vs CCR Protocol 2004 – 2005 x (33)

Kellum et al Amer J of Medicine 2006; 119, 335-340

EMS – Document Regurgitation on the scene

Chest compression only CPRThe OSAKA registry

Osaka, Japan

8.8 million residents

The EMS system is operated by the 35 local fire stations

115,000 citizens per year participated in the conventional CPR training (chest compressions and mouth to mouth ventilation)

The mean population-based incidence of out-of-hospital cardiac arrest in Osaka was 63 per 100,000 person-years

Iwami et al, Circulation 2007;116:2900-07

Chest compression only CPRThe OSAKA registry

No CPR Cardiac only Conventional CPR

Primary outcome

Favorable 1-y neurol. outcome (%)

2.1 3.5 3.6

VF as initial rhythm (%) 15.4 22.9 21.4

ROSC (%) 34.6 35.2 35.4

Survival at 1 month (%) 5.9 6.9 7.8

Survival at 1 year (%) 3.5 5 5.5

Witnessed VF cardiac arrests

Favorable 1-y neurol. outcome (%)

8.2 11.5 11.2

Iwami et al, Circulation 2007;116:2900-07

Neutral

Chest compression only CPRSurvey Of Survivors of out-of-Hospital Cardiac Arrest in the Kanto region of Japan (SOS-KANTO)

Prospective, multicentre, observational study of patients who had out-of-hospital cardiac arrest.

On arrival of the scene, the paramedics assessed the technique of bystander resuscitation.

The primary end-point was favorable neurological outcome 30 days after cardiac arrest.

4068 adult pts who had o-f-h cardiac arrest witnessed by bystanders were included; 11% received cardiac only resuscitation from bystanders, 18% conventional CPR and 71% received no bystander CPR

SOS-Kanto study group, Lancet 2007;369:920-6

Chest compression only CPRSurvey Of Survivors of out-of-Hospital Cardiac Arrest in the Kanto region of Japan (SOS-KANTO)

6,2

3,1

19,4

11,210,1

5,1

0

2

4

6

8

10

12

14

16

18

20

Pts with

apnoea

Shockable

rhythm

CPR within

4 min of

arrest

Cardiac only CPR (%)

Conventional CPR (%)

P=0.0221

P=0.041

P=0.0195

SOS-Kanto study group, Lancet 2007;369:920-6

Let's say they can't tell the difference. Doing chest-compression-only CPR will save more people for the simple fact that it's easier to do, and people are more likely to do it. Michael R Sayre (2008)

Borbow B, (Circulation. 2009;120:S1443.)

Conclusion

There is one clinical observational study (Kellum-2006) demonstrated a better survival with a resuscitation protocol incorporating CC-CPR instead of the conventional (AHA 2000 guideline 15:2) approach (LOE3).

Demonstrated that (OOHCA) cardio cerebral resuscitation (CCR) increase survival BUT......

Incorporates CC-CPR for the first stage of resuscitation carried out by professional responders (EMTs) and NOT by lay public.

Conclusion

Manikin Study: Good LOE 5

20 (females) certified in BLS

CC Rate & Depth Vs fatigue

Trowbridge et al, BMC Nursing 2009, 8:6

40 piglets:

4 groups X 10.

1. CC+V,

2. CC only,

3. V only,

4. No CPR.

Berg et al Circulation 2000;101;1743-1748. CPR for Asphyxia

EXPERIMENTAL PAPER

“Impact of different compression—ventilation ratios during basic

life support cardiopulmonary resuscitation”

Erol Cavus et al Resuscitation (2008) 79, 118—124

Erol Cavus et al Resuscitation (2008) 79, 118—124

“Oxygen delivery and return of spontaneous

circulation with ventilation:compression ratio 2:30

versus chest compressions only CPR in pigs”E. Dorph et al. / Resuscitation 60 (2004) 309–318

chest compressions only

ratio 2:30

“Oxygen delivery and return of spontaneous

circulation with ventilation:compression ratio 2:30

versus chest compressions only CPR in pigs”E. Dorph et al. / Resuscitation 60 (2004) 309–318

Experimental paper

“Basic life support with four different compression/ventilation

ratios in a pig model: The need for ventilation”

C. Kill et al. / Resuscitation 80 (2009) 1060–1065

Experimental paper

“Basic life support with four different compression/ventilation

ratios in a pig model: The need for ventilation”

ROSC

C. Kill et al. / Resuscitation 80 (2009) 1060–1065

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

5

ROSC

30-2

100-2

100-5

CC-ONLY

Experimental paper

“Oxygen requirement during cardiopulmonary resuscitation

(CPR) to effect return of spontaneous circulation”

Steve T. Yeh, Resuscitation 80 (2009) 951–955

Experimental paper

“Oxygen requirement during cardiopulmonary resuscitation

(CPR) to effect return of spontaneous circulation”

Steve T. Yeh, Resuscitation 80 (2009) 951–955

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

ROSC 72 Hrs Survival

0% O2

21% O2

100% O2

MANIKIN AND SIMULATION STUDY

“Quality of lay person CPR performance with compression:ventilation ratios

15:2, 30:2 or continuous chest compressions without ventilations on

manikins”

Silje Odegaard Resuscitation (2006) 71, 335—340

Volunteers from Oslo International Airport

Consensus on Science –CPR with CC ONLY

Health care professionals & rescuers, unwilling to do ―mouth to mouth‖

Animal studies demonstrated that CC Only may be equally effective as conventional CPR but for the first few minutes.

Animal studies with CC Only shown that arterial O2 concentration significantly reduced after 2 – 4 minutes.

Results with CC ONLY CPR with no ventilation are significantly better when compared with no CPR BUT in in non hypoxic cardiac arrests.

Several human studies shown that CC ONLY are equally effective as conventional CPR BUT do not exclude the possibility of being effective than conventional CPR.


CPR with CC ONLY is effective only the first few minutes after collapse.

NOT as effective as conventional CPR in children, drowning and asphyxiated cardiac arrests.

ERC Guidelines 2010


THEREFORE

Trained rescuers should attempt CPR with combination of Chest compressions and rescue breathing.

Lay bystanders are encouraged to attempt CC Only CPR in the following cases:

when not trained and unwilling to mouth to mouth breathing.

When telephone instruction CPR is performed.

these should be at a rate of 100min-1 but not exceeding 120 min-1.

ERC Guidelines 2010

THANKS

Nicosia

efccna congress march 2011 01/session...conclusion there is one clinical observational study...

Documents