Science Driving the Future of Basic Life Support

Paris Hotel and Casino Las Vegas, Nevada

Presented by:Dana Edelson, MD, MS, FAHA, FHM

Medical Director of Rescue Care and ResiliencyUniversity of Chicago Medicine

Presenter Disclosure Information

Dana Edelson

Science Driving the Future of Basic Life Support

FINANCIAL DISCLOSURE: Employed by the University of Chicago Grants from the National Institutes of Health, Philips

Healthcare, American Heart Association, Laerdal Medical Ownership interest in Quant HC and intellectual property

for analytics related to predicting in-hospital cardiac arrest

UNLABELED/UNAPPROVED USES DISCLOSURE: None

History of Resuscitation Liss. Ann Emerg Med 1986; 15:65-72.

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1500 1600 190018001700

Bellows Method (1500s)

Rolling Method (1856)

Side to side compression (1831)

Barrel Method (1700s)

Prone compression (1903)

Development of closed chest cardiac massage (1960)

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Introduction of CPR sensing defibrillators (2005)

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Resuscitation Eras

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Early resuscitation

1740-1960

Qualitative CPR

1960-2005

Quantitative CPR

2005-presentMouth to mouth ventilation endorsed in Europe

Early methods of chest compression taught

Closed chest cardiac massage published

AHA holds first CPR course

CPR measuring defibrillators available

IHCA and OHCA CPR quality published

Baseline CPR Quality

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January 19, 2005

Hands off

Compression Fraction:

Abella, JAMA, 2005Baseline CPR quality by trained rescuers

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FastSlow

Compression Rate:

Too shal-low

Compression Depth:

FastSlow

Ventilation Rate:

• Previously by Kramer-Johanson J, 2006; Edelson DP, 2006; Stiell, 2012

• Vadeboncoeur, Resuscitation, 2014

Chest compression: deeper seems better yet again

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1-Jan-07 2-Jan-070

0.5

1

1.5

2

2.5

Survivors Non- Survivors

Mea

n Co

mpr

essi

on D

epth

, mm

1. A decrease in rate (Vadeboncoeur, 2014)

2. An increase in leaning (Robertson-Dick, 2010)

Caution: an increase in depth often comes with

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Idris, Circulation, 2012Fast but not too fast…

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Pauses in chest compression are bad

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94%

72%

60%

38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

≤10 10.1-20 20.1-30 >30Pre-Shock Pause, Seconds

Sh

ock

Su

cces

s, P

erce

nt

n=17 n=8n=10n=18

-Edelson, 2006; Rea, 2006; Sell, 2010; Christensen, 2009; Cheskes, 2013

• Worsen hemodynamics

• Associated with poor outcomes

• Clinical data sparse

– Aufderheide, 2004– Niles, 2011

Hyperventilation and leaning are detrimental in animals

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Updates on feedback, debriefing and mechanical CPR for improving CPR quality and patient outcomes

Now that you can measure…

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Impact of feedback on compression depth Abella, Resus, 2007

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Hostler, BMJ, 2011

IHCA OHCA

Impact of feedback on compression rate Abella, Resus, 2007

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Hostler, BMJ, 2011

IHCA OHCA

Feedback + situational training

Pre-intervention

Post-intervention

P-value

Compression depth

44 mm 54 mm <0.05

Compression rate

126/min 105/min <0.05

Compression fraction

0.66 0.84 <0.05

Ventilation rate 12/min 10/min <0.05

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Bobrow, Ann Emerg Med, 2013

Debriefing

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Results: CPR at goal over time Abella, Resuscitaton, 2007

Edelson, Arch Int Med, 2008

Ventilation rate

Compression rate

Compression depth

Compression fraction

0%

20%

40%

60%

80%

100%

Baseline Feedback Feedback/debriefing

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Feedback + debriefing

Results: Return of circulation Edelson, Arch Int Med, 2008

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Baseline Feedback Feedback + debriefing

0%

10%

20%

30%

40%

50%

60%

p=0.03

Pediatric Debriefing Data Wolfe, Crit Care Med, 2014

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Pediatric Debriefing Outcomes

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Wolfe, Crit Care Med, 2014

Integrated Automated Load Band Distributing CPR

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June 14, 2006

Hallstrom et al. Multicenter, randomized

Early discontinuation↓ survival to discharge:

9.9%5.8% (p=0.06)↓ neurologically intact survival:

7.5%3.1% (p=0.006)

Ong et al. Richmond, VA. historical control

↑ROSC: 20.2%34.5%*↑Survival to discharge:

2.9%9.7%* *p<0.05

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Circ Trial Outcomes – no difference

Compression fraction 0.80 in both groups!!!

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• High-quality CPR should be recognized as the foundation on which all other resuscitative efforts are built

• Continually adjust resuscitative efforts based on the patient’s physiological response

• Capture CPR performance data in every cardiac arrest and use an ongoing CPR CQI program to optimize future resuscitative efforts

Final Consensus Recommendations Meaney et al, Circulation, 2013

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• Target CPR performance metrics:– CCF >80%– Compression rate of 100–120/min– Compression depth of ≥50 mm in adults with no residual leaning

• (At least one third the anterior-posterior dimension of the chest in infants and children)

– Avoid excessive ventilation•  (Only minimal chest rise and a rate of <12 breaths/min)

Recommendations (cont)

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Meaney et al, Circulation, 2013

New data supports import of high quality CPR

Compression rate recommendations should likely include an upper limit

Data in support of real-time feedback is strengthened, though still no outcome benefit

Data in support of debriefing now includes a possible pediatric survival benefit

High quality manual CPR is equivalent to integrated automatic load-distributing band CPR

Conclusions

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Thank you

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Acknowledgements

• Ben Abella, MD, MPhil• Lance Becker, MD• Trevor Yuen• Brian Robertson-Dick, MD• Meredith Borak, RN, MSN• Matt Churpek, MD, MPH, PhD• Frank Zadravecz, MPH• Nicole Twu, MS

Questions?