cpr that saves lives

CPR That Saves Lives, Not Just ACLS for Dermatologists

Salim R. Rezaie, MDTwitter: @srrezaie

Disclosures

Objectives

Cardio Cerebral Resuscitation (CCR)

Ewy GA et al. Curr Opin Cardiol 2008

Evidence to Support CCR

ROSC 24h Survival Neuro Intact 24h Survival

0%10%20%30%40%50%60%70%80%90%

40.0%26.7%

13.3%

86.7% 86.7%80.0%

ABC CPR CCC CPR 15 Pigs Per Arm

More Animal Studies

Annals of EM 2002

Crit Care Med 2010

Resuscitation 2010

Compression only CPR IMPROVED1. Coronary Perfusion Pressure2. ROSC3. 24 Hour Survival4. Neuro Outcomes This is What We Care About

Neuro Intact Meaning

Human Studies Supporting CCR

Ann Emerg Med 2008

2001 2002 2003 2004 2005 20060%

10%

20%

30%

40%

50%

60%

23% 23%

15%

58%

38%44%

19%23%

8%

48%

29%

38%

Survivors Neuro Intact Survivors

CCR CPR

Standard CPR

Coronary Perfusion is Dependent on Active CPR

Cunningham LM et al. American Journal of Emergency Medicine 2012

Inadequate Perfusion Pressure

Cunningham LM et al. American Journal of Emergency Medicine 2012

CPR Pause Evaluation

Pre-Shock Pause <10s

Pre-Shock Pause >20s

Peri-Shock Pause < 20s

Peri-Shock Pause >40s

Post-Shock Pause <10s

Post-Shcok Pause >20s

35.1%

25.1%

32.6%

20.3%

31.8%

22.7%

Survival

Pre-ShockPeri-Shock

Post-Shock*

Circulation 2011*Not Statistically Significant

How Good Are We At CPR Rates

97 Arrests 813 Minutes of Resuscitation (CPR)

Suboptimal Compression Rate

CPR Rate < 70 = 21.7%

CPR Rate < 80 = 36.9%

CPR Rate > 100 = 31.4%

“Hands-On” Defibrillation

Mechanical CPRDoes Mechanical CPR Improve Neurologically Intact Outcomes?

“Hands-On” Defibrillation SAFE

Circulation 2008

43 Simulated Shocks

NO shocks perceivedby rescuers

“Hands-On” Defibrillation NOT SAFE

Resuscitation 2012

VinylLatexNitrile

Chloroprene

Current LeakageGlove Breakdown

Increased Defibrillation

Voltage

Current Leakage and/or Breakdown of Gloves Within Output Range of Biphasic Defibrillator

NONE 100% Safe

Safety of External Defibrillation

Systematic Literature Review

29 Adverse Events– 15 During Regular Resuscitation Efforts

Resuscitation 2009

Resuscitation 2014

Case Report of 1

www.rebelem.com

CPR During Defibrillator Charging

Pre-Shock Pause Post-Shock Pause Peri-Shock Pause0

5

10

15

20

25

16

4

21

3 3

7

Non-CDC CDC

Tim

e (S

econ

ds)

Sample size Not Large Enough For Clinical Outcomes

Resuscitation 2014

“Hands-On” Defibrillation Bottom Line

Does “Hands-On” Defibrillation Decrease Pre-Shock Pauses?

Does “Hands-On” Defibrillation Improve Neuro Intact Survival Outcomes?

Is “Hands-On” Defibrillation Safe?

YES

UNCLEAR

UNCLEAR

Mechanical vs Manual CPR

Load Distributing Band (LDB) Piston Driven (PD)

Why it Matters

MechanicalIncrease Rate

Increase Depth

Decreased Interruptions

Should Equal

Increased Survival

ManualDecrease Rate

Decrease Depth

Increased Interruptions

Should Equal

Decreased Survival

Most Recent Meta-Analysis

12 Studies (8 LDB and 4 PD)

6,538 Patients

Primary Outcome = ROSC

Crit Care Med 2013

Results

Limitation

Does ROSC = Increased Survival with Good Neurological Outcomes

Crap In = Crap Out

Best Quality Evidence

PD vs Manual CPR

LDB vs Manual CPR

LDB vs Manual CPR

ROSC* Hosp D/C with CPC ≤ 20.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

28.5%

3.1%

29.5%

7.5%

LDB CPR Manual CPR

Hallstrom et al JAMA 2006

*Not statistically significant

Limitation

LDB CPR Group80 Compression/min

Manual CPR Group100 Compression/min

LUCAS In Cardiac Arrest (LINC) Trial

4 Hr Survival* 1 Mo Survival w/ CPC ≤ 2* 6 Mo Survival w/ CPC ≤ 2*0

5

10

15

20

25 23.6

7.58.5

23.7

6.47.6

PD CPR Manual CPR

LINC Trial JAMA 2014*Not Statistically Significant

Time for Application of Device

Time Without CPR

Time to 1st Defibrillation

Hallstom et al = 2.1 minutes longer until 1st defibrillationLINC Trial = 1.5 minutes longer until 1st defibrillation

Not Recorded

Mechanical CPR Bottom Line

1. Does Mechanical CPR Improve Neurologically Intact Outcomes?

NO

Clinical Bottom Line

“Hands-On” Defibrillation – DECREASES CPR Interruptions– UNCLEAR Neuro Intact Survival– UNCLEAR Safety

Mechanical CPR– DOES NOT Improve Neuro Intact Outcomes