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 Points1. 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

0% 20% 40% 60% 80%

40-72

72-87

87-95

96-139

ROSC

No ROSC

p < 0.0083

Abella et al. Circulation. 2005;111:428-434

What’s the optimal rate?

Circulation (2012) Jun 19;125(24):3004-12

95%

CI

100 - 120

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

Christenson et al. Circulation (2009)

> 80%

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)

Is it really gender?

• Probably

not…

Hasegawa et al. J

Physiological

Anthropology

2014, 33:16

CPR Skill Decay

34%

27%

10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3 months 6 months 12 month

Average Skill Loss

% P

assin

g S

kill

s T

est

www.heart.org/HEARTORG/General/Resuscitation-Quality-Improvement_UCM_459324_SubHomePage.jsp

How do you measure rate?

Download your monitor/defib

• Real time coaching

• Good data to support

metronome use in

both training and

actual CPR

events

Metronome?

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

• Base plate creates 3-dimensional magnetic fields

• Top piece senses field

• Calculates true Anterior/Posterior depth

• Does not require exact alignment

1

2

TrueCPR Coaching Device

Metronome

Depth dial

Rate

Event timer

TrueCPR Summary Report

Green: Target depth and rate zones

Yellow: Pauses

Hospital Issues:

1. Bed Height

– Optimal = bed at knee level of person

administering chest compressions

Cho et al, Emerg Med J. 2009;26:807-810

2. Air Mattresses

– No need to deflate mattress for CPR

Perkins et al, Inten Care Med. 2003;29:2330-2335

3. Backboards

– No evidence of benefit with backboardPerkins et al, Inten Care Med. 2003;29:2330-2335

CPR is Complicated!

Mechanical piston CPR

Multiple StudiesGenerally equivalent in outcomes when

compared to manual CPR

So when might they help?

1. Provider mix

2. Long resuscitationsa. 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)

• Simulated CPA in pigs; coronary blood flow1

– CPP: 20-25 mmHg LUCAS vs. 5-10 mmHg manual

– EtCO2: 25.5 mmHg LUCAS vs. 16.5 mmHg manual

• EtCO2 measurement in humans2

– EtCO2 values higher in LUCAS patients

– 126 OHCA patients

– Average 24.5 mmHg vs. 20.4 mmHg

Woman vs. Machine?

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 (PETCO2) 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 fever

WBCs, etc

Cardiac Arrest

CPR CPR

Was ABX given?

Waveform CapnographyAttaches to ET tube, measures CO2

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…

Thanks for your attention!

www.mikemcevoy.com