What is the ideal chest compression:ventilation ratio? Ventilation : Perfusion Match• Good CPR ~1/4 - 1/3 of normal

cardiac output• alveolar ventilation ~1/4 - 1/3 of

normal• Additional breaths

– “dead space” ventilation– Increase IT pressure

CPR ratios

Babbs, Resuscitation 2004;61

Mathematical model

Lay rescuers - adultvictims

50:2 “best”

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Guidelines 2005- Ventilation

• Compression/Ventilation Ration 30:2• Deliver each rescue breath over 1 second• Give enough volume to produce visible chest rise• Avoid rapid and forceful breaths• Advanced Airway- give 1 breath every 6-8 seconds

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Chest Compressions Only Continuous chest compression (CCPR)

Shock First or CPR First

• Emphasis

effective chest compression defibrillation

Survival From Simulated CPR Survival From Simulated CPR

Ewy et al: Circulation 2005;111:2134-42Ewy et al: Circulation 2005;111:2134-42

00

4040

8080

24 h

r C

NS

NO

RM

24 h

r C

NS

NO

RM

CC Only IDEAL CPR NO CPR

73% 70%

7%

Wik, L. et al. JAMA 2003;289:1389-1395.

Probability of Survival to Hospital Discharge

0

10

20

30

40

50

60

ROSC Hosp DC 1 YR

Defib

CPR

Defibrillation or CPR First

Wik, JAMA 2004

%

surv

ival

Phases of VF Cardiac Arrest

Metabolic PhaseMetabolic PhaseGLOBAL ISCHEMIA-INJURYGLOBAL ISCHEMIA-INJURY

Electrical PhaseMINIMAL ISCHEMIA

Hemodynamic PhaseLOCAL ISCHEMIA

RIGHT HEART V-P

JAMA 2002;288:3035

Phases of VF Cardiac Arrest

Metabolic PhaseMetabolic PhaseNOVEL THERAPIES NEEDEDNOVEL THERAPIES NEEDED

Electrical PhaseEARLY DEFIBRILLATION CRITICAL

Hemodynamic PhaseCORONARY-CEREBRAL PERFUSION PRESSURE

CRITICAL

JAMA 2002;288:3035

DEFIBRILLATION

4MINS

CHEST COMPRESSIONHDE

4-10MINS

HYPOTHEMRIACONTROLLED REPERFUSION

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Guidelines 2005- CPR before Defibrillation

• Immediate defibrillation is the treatment of choice for VF of short duration

• OOH unwitnessed (EMS) VF, may give period CPR before rhythm check

• Emphasis

effective chest compression defibrillation

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Single or Stacked Shocks

Pulse Check

Rhythm Check

Single shock

Followed by immediate CPR

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Major Recommendations

1st Shock delivered

22 seconds after pads placed

RE-VF 25 seconds after the 1st shock

(No Chest Compressions yet)

2nd Shock delivered 34 sec after re-VF

(Still No Chest Compressions)

CPR finally begun after 1 min 17 sec from 1st shock

N Waveform Energy

1st 2nd 3rd

54 BTE

150, 150,15096% 96% 98%

48 MTE

200, 200, 36054% 60% 67%

13 MDS

200, 200, 36077% 77% 77%

Monophasic vs Biphasic WaveformShock Efficacy VF

No waveform consistently related to ROSC or Hospital Discharge

Defibrillation Success Out-of-Hospital Cardiac Arrest

First Shock Results (N=21/61)

Remained in VF- 19% Shocked into Non-VF 81%Perfusing rhythm 0%

Kern Circulation 2002

@TIME RESUME CPR – 45 SECONDS

Prompt CPR after AED

0

10

20

30

40

50

60

ROSC 48-Hour Good Neuro

STD AED Prompt CC

Per

cent

‘p’ <0.05

3/18

3/18 3/18

10/189/18 9/18

Kern

Will CPR Do Harm Post-Shock

• Most ‘post-shock” PEA is “pseudo-PEA” -some pressure generated (~10/5 or 20/10 mmHg) -undetectable as a palpable pulse (Aufderheide/Monday)

• Chest Compressions during post-shock organized rhythms does not precipitate re-VF (Hess & White)

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Guidelines 2005- CPR after Defibrillation

• Resume CPR immediately following shock (and while charging)

• No pulse or rhythm check for 5 cycles CPR (@ 2 minutes)

• Emphasis advanced airway

• Recommendation Intraosseous access

Emphasis ET

drug administration

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ACLSMajor Recommendations

ACLS PRIORITIES2 MINUTE CYCLES- TEAM DYNAMICS

ECC – New Course Emphasis

• Team Dynamics and Leadership

• Outcome is determined by success of team and not the individual

• Amiodarone – Lidocaine

either

• Epinephrine- Vasopressin

ET discouraged

• Atropine 0.5 mg - ACS

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ACLSMajor Recommendations

Summary ACLS• Emphasis on High-Quality CPR• Simplified Algorithms

– Recommend expert consultation

• Use IV / IO Access– limit ET administration

• Limit, defer Advanced Airway Use – Especially endotracheal tube

• Primary confirmation of ET- dual method

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Key studies- AmiodaroneKey studies- Amiodarone

ARREST TRIAL Kudenchuck 1999ARREST TRIAL Kudenchuck 1999Patient Patient groupgroup

nn Survival to Survival to admissionadmission

Odds ratio for Odds ratio for admissionadmission

Survival to Survival to dischargedischarge

AmiodaroneAmiodarone 246246 44 %44 % 1.61.6 13.4 %13.4 %

PlaceboPlacebo 258258 34 %34 %

(p = 0.03)(p = 0.03) (p = 0.02)(p = 0.02)

13.2 %13.2 %

(p = ns.)(p = ns.)

amiodarone 5 mg/kg vs. lidocaine 1.5 mg/kg)amiodarone 5 mg/kg vs. lidocaine 1.5 mg/kg)

Patient groupPatient group nn Survival to Survival to admissionadmission

Survival to Survival to dischargedischarge

AmiodaroneAmiodarone 180180 22.8 %22.8 % 5 %5 %

LidocaineLidocaine 167167 12.0 % 12.0 %

(p = 0.009)(p = 0.009)

3 %3 %

(p = 0.34)(p = 0.34)

ALIVE TRIAL Dorian 2002ALIVE TRIAL Dorian 2002

Lindner 1997Lindner 1997

GroupGroup nn ROSCROSC Survival Survival

admissionadmissionSurvivalSurvival

≥ ≥ 24 h24 hSurvivalSurvival

dischargedischarge

VasopressinVasopressin 2020 80 %80 % 70 %70 % 60 %60 % 40 %40 %

EpinephrineEpinephrine 2020 55 %55 %(p = 0.18)(p = 0.18)

35 %35 %(p = 0.06)(p = 0.06)

20 %20 %(p = 0.02)(p = 0.02)

15 %15 %(p = 0.16)(p = 0.16)

Vasopressin-Epinephrine

Vasopressin-EpinephrinePatient groupPatient group

(all rhythms)(all rhythms)

nn Survival to 1 Survival to 1 hourhour

Survival to Survival to dischargedischarge

VasopressinVasopressin 104104 39 %39 % 12 %12 %

EpinephrineEpinephrine 9696 35 %35 %(p = 0.66)(p = 0.66)

14 %14 %(p = 0.67)(p = 0.67)

PEAPEA

n = 95n = 95

Survival Survival

to 1 hourto 1 hour

Survival Survival

dischargedischarge

VasopressinVasopressin 33 %33 % 9 %9 %

EpinephrineEpinephrine 29 %29 % 10 %10 %

Stiell 2001

Stiell 2001Stiell 2001

VF/VTVF/VT

(n = 42)(n = 42)

Survival Survival

1 hour1 hour

SurvivalSurvival

dischargedischarge

VasopressinVasopressin 54 %54 % 25 %25 %

EpinephrineEpinephrine 61 %61 % 33 %33 %

Wenzel 2004Wenzel 2004

VF/VTVF/VT

(n = 188)(n = 188)

ROSCROSC Survival Survival admissionadmission

Survival Survival dischargedischarge

VasopressinVasopressin 36.8 %36.8 % 46.2 %46.2 % 17.8 %17.8 %

EpinephrineEpinephrine 42.6 %42.6 %(p = 0.20)(p = 0.20)

43.0 %43.0 %(p = 0.48)(p = 0.48)

19.2 %19.2 %(p = 0.70)(p = 0.70)

Vasopressin-Epinephrine

Patient group Patient group (all rhythms)(all rhythms)

nn ROSCROSC Survival Survival admissionadmission

Survival Survival dischargedischarge

VasopressinVasopressin 589589 24.6 %24.6 % 36.3 %36.3 % 9.9 %9.9 %

EpinephrineEpinephrine 597597 28.0 %28.0 %(p = 0.19)(p = 0.19)

31.2 %31.2 %(p = 0.06)(p = 0.06)

9.9 %9.9 %(p = 0.99)(p = 0.99)

Subgroup Subgroup

with PEAwith PEA

n = 186n = 186

N=18N=1866

ROSCROSC Survival Survival admissionadmission

Survival Survival dischargedischarge

VasopressinVasopressin 104104 20.2 %20.2 % 33.7 %33.7 % 5.9 %5.9 %

EpinephrineEpinephrine 8282 20.7 %20.7 %(p = 0.93)(p = 0.93)

30.5 %30.5 %(p = 0.65)(p = 0.65)

8.6 %8.6 %(p = 0.47)(p = 0.47)

Vasopressin-Epinephrine

Wenzel 2004

Summary BLS HCP

• Lone HCP- Tailor Sequence Actions

• Check for Adequate Breathing

• Open airway in trauma patients

• Avoid Excessive Ventilation (too fast, too much)– 1 breath Q 8-10secs

• 30:2 compression ventilation ratio

• Continuous CPR with advanced airway

• Rescuers rotate every two seconds

• Push hard, push fast, allow full chest recoil

• Pulse check >5 10 seconds

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