the evidence behind acls: the importance of good bls crs
TRANSCRIPT
The evidence behind ACLS: the importance of good BLS
Benjamin S. Abella, MD, MPhil, FACEP Clinical Research Director
Center for Resuscitation Science Vice Chair of Research
Department of Emergency Medicine University of Pennsylvania
Laerdal Workshop – December 2014
CRS Center for
Resuscitation Science
Time
% S
urvi
ving
arrest
CPR defibrillation
ROSC
hospital discharge
Cardiac arrest is the ultimate EMS disease!
1961
50 years of modern CPR
A. Peter Safar, 1950s
B. Early symposium on CPR
A B
“Chain of Survival”
Prompt Access
Early CPR
ACLS Care
Early Defib
ACLS Provider Manual (American Heart Association)
Cardiac arrest: fundamentals of therapy
Bystander contacted 9-1-1
standard CPR (n=960) chest compression alone (n=981)
Chest compression alone CPR
2010
Survival to DC
11.5% 14.4% (OR 2.9)
Berg et al, 2001
Blo
od
pre
ssur
e
Time
= chest compression
Standard CPR vs CC alone
Berg et al, 2001
Blo
od
pre
ssur
e
Time
= chest compression
Standard CPR vs CC alone
“No flow” / compression fraction
0-20 21-40 41-60 61-80 81-100 comp fraction, %
Surv
iva
l to
dis
cha
rge
, %
0
10
2
0
3
0
Christenson J et al, Circ 2009 poor survival with lowest compression fraction in OHCA
40
32
24
16
8
0 1 2 3 CPR duration, min
CPP
, mm
Hg
ICCM, 2005
2 inches vs 1.5 inches Survival: 100% 15%
Chest compression depth
Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation
Defib first - AHA CPR (90 sec) first, then defib 42 months 36 months
24% (155/639) 30% (142/478) p=0.04
Cobb et al, 1999
CPR first may improve survival
0 2 4 6 8 10 12 14
0.5
0.4
0.3
0.2
0.1
0
Wik et al, 2003
CPR first Standard care
pro
ba
bili
ty o
f sur
viva
l
time from collapse, min
CPR first may improve survival: RCT
p=0.006
CPR sensing and recording defibrillator
Similar defibrillators now made by both Philips and Zoll
Using CPR feedback to improve quality
Kramer Johansen, 2006
Abella, 2007
ventilations
ECG
compressions
rhythm check ECG: v fib
shock given
Arrest transcript
ECG: v tach
Actual arrest transcript: U of C, 2004
10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 R>120
Chest compression rate (min-1)
Num
be
r of 3
0 se
c s
eg
me
nts
300
250
200
150
100
50
0
n=1626 segments
Chest compression rates
Abella et al, 2005
No ROSC ROSC
10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 >120
Chest compression rate (min-1)
Mean rate, ROSC group 90 ± 17 *
Mean rate, no ROSC group 79 ± 18 *
210 180 150 120 90 60 30 0
Num
be
r of 3
0 se
c s
eg
me
nts
Chest compression rates by survival
Abella et al, 2005
p=0.003
CPR renaissance: measuring CPR
Valenzuela et al, Circ 2005 Wik et al, JAMA 2005 Abella et al, JAMA 2005 Aufderheide et al,Circ 2004
Aufderheide et al, 2004
mean ventilation rate: 30 ± 3.2
first group: 37 ± 4 after retraining: 22 ± 3
16 seconds
v v v v v v v v v v
Hyperventilation during EMS resuscitation
Pause before shock
4:55 5:00 5:05 5:10
Com
pres
sion
s
ECG
Chest compression pauses before shocks
0
20
40
60
80
100
≤10.3 (n=10)
10.5-13.9 (n=11)
14.4-30.4 (n=11)
≥33.2 (n=10)
Pre-shock pause, seconds
VF re
mov
ed, p
erce
nt
90%
10%
55% 64%
p=0.003
Dose-effect of pre-shock pauses
Edelson et al, 2006
50%62%
93%100%
0%
20%
40%
60%
80%
100%
120%
<1 1-1.5 1.5-2 >2
Shoc
k su
cces
s, p
erce
nt
Compression depth, inches
ACLS Range
n=10 n=5 n=14 n=13
p=0.02
Shock success by compression depth
Edelson et al, 2006
Improving EMS care with “CC only”
Bobrow et al, 2008
Interventions: 1. Significantly delay intubation 2. 200 compressions before first shock 3. Minimize pre and post shock pauses
Tripled survival to hospital discharge (3.8% à 9.1%)
Improving EMS care with “CC only”
2009
Confirmation of this finding:
How to train for quality
l Code review investigation:
– All residents and students rotating through resuscitation team roles
– Debrief teams on their events
– Weekly 30-45 min resuscitation debriefing/teaching sessions
Debriefing intervention
Impact of CPR feedback and debriefing
Edelson et al, 2008
Impact of CPR feedback and debriefing
Edelson et al, 2008
Impact of CPR feedback and debriefing
EMS version of the Edelson 2008 study Performed using Zoll feedback defibrillators in Arizona
Impact of CPR feedback and debriefing
The key importance of CPR
2009
Reflected in the poor impact of ACLS meds:
Randomized trial of epinephrine versus no epinephrine For EMS treated cardiac arrest à NO SURVIVAL BENEFIT!
Key “take home” points
1. Cardiac arrest is not hopeless!
2. CPR quality has big impact
3. Minimize ventilations
4. Maximize chest compression rate and depth
5. Consider CPR feedback tools and code debriefing
6. Use hypothermia after cardiac arrest
Questions?
?