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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
