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This is a slightly updated version of a previous lecture on the science behind CPR. I have deleted the older version to avoid confusion, though they are both essentially the same This lecture is good for first responders of all levels (from lifegaurds to paramedics) to really bring home the importance of CPR. It has been my experiance that current CPR classess are lacking in this regard, therefore compliance with new CPR standards is lacking, and this promotes LAZY CPR. This is my attempt to remedy that issue.
Citation preview
Importance of CPR
Robert S Cole
Credit where Credit is Due
bull Adapted from presentation by Ahamed Idris MD ndash Professor of Emergency Medicine University
of Texas Southwestern Medical Center at Dallas
Special Thanks
bull Dr Peter Safarbull Father of
Resuscitation medicine
bull Helped develop CPRbull Directly responsible
for the research used in therapeutic hypothermia
Objectives
bull Importance of maximizing CPRbull Why compressionventilation ratio 302 bull Complete chest wall recoilbull Danger of hyperventilationbull CPR First vs shock firstbull 1 shock vs 3 shocksbull Minimize delay to shockbull Impedance Threshold Device (ITD) Science
Why I am doing this lecturehellipWhy I am doing this Why I am doing this lecturehelliplecturehellip
A need for changehellip
bull Approximately 350000 persons die from out-of-hospital cardiac arrest each year in North America
bull Survival rate is poor among these patients and most do not survive to hospital discharge
bull New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought
bull Other research suggests that an impedance threshold device (ITD) may improve outcome
CPR in Hollywoodhellip
bull ROSC (Getting a pulse back) 75bull discharged neurologically Intact 67
CPR in Real Life
bull ROSC between 01 and 49ndash 3-7 typical
bull Survival to Hospital Admission 23
bull Survival to Discharge 76ndash THIS HAS NOT IMPROVED SIGNIFICANTLY
IN 30YEARS
bull Good Neurological Outcome 01 and 30
Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10
2009 doi101161CIRCOUTCOMES1098895 6
Today Nearly everyone dieshellip
But there is hopehellip
Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits
Importance Of CPR
10-20 of normal blood flow to the heart
20-30 of normal blood flow to the brain
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Credit where Credit is Due
bull Adapted from presentation by Ahamed Idris MD ndash Professor of Emergency Medicine University
of Texas Southwestern Medical Center at Dallas
Special Thanks
bull Dr Peter Safarbull Father of
Resuscitation medicine
bull Helped develop CPRbull Directly responsible
for the research used in therapeutic hypothermia
Objectives
bull Importance of maximizing CPRbull Why compressionventilation ratio 302 bull Complete chest wall recoilbull Danger of hyperventilationbull CPR First vs shock firstbull 1 shock vs 3 shocksbull Minimize delay to shockbull Impedance Threshold Device (ITD) Science
Why I am doing this lecturehellipWhy I am doing this Why I am doing this lecturehelliplecturehellip
A need for changehellip
bull Approximately 350000 persons die from out-of-hospital cardiac arrest each year in North America
bull Survival rate is poor among these patients and most do not survive to hospital discharge
bull New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought
bull Other research suggests that an impedance threshold device (ITD) may improve outcome
CPR in Hollywoodhellip
bull ROSC (Getting a pulse back) 75bull discharged neurologically Intact 67
CPR in Real Life
bull ROSC between 01 and 49ndash 3-7 typical
bull Survival to Hospital Admission 23
bull Survival to Discharge 76ndash THIS HAS NOT IMPROVED SIGNIFICANTLY
IN 30YEARS
bull Good Neurological Outcome 01 and 30
Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10
2009 doi101161CIRCOUTCOMES1098895 6
Today Nearly everyone dieshellip
But there is hopehellip
Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits
Importance Of CPR
10-20 of normal blood flow to the heart
20-30 of normal blood flow to the brain
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Special Thanks
bull Dr Peter Safarbull Father of
Resuscitation medicine
bull Helped develop CPRbull Directly responsible
for the research used in therapeutic hypothermia
Objectives
bull Importance of maximizing CPRbull Why compressionventilation ratio 302 bull Complete chest wall recoilbull Danger of hyperventilationbull CPR First vs shock firstbull 1 shock vs 3 shocksbull Minimize delay to shockbull Impedance Threshold Device (ITD) Science
Why I am doing this lecturehellipWhy I am doing this Why I am doing this lecturehelliplecturehellip
A need for changehellip
bull Approximately 350000 persons die from out-of-hospital cardiac arrest each year in North America
bull Survival rate is poor among these patients and most do not survive to hospital discharge
bull New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought
bull Other research suggests that an impedance threshold device (ITD) may improve outcome
CPR in Hollywoodhellip
bull ROSC (Getting a pulse back) 75bull discharged neurologically Intact 67
CPR in Real Life
bull ROSC between 01 and 49ndash 3-7 typical
bull Survival to Hospital Admission 23
bull Survival to Discharge 76ndash THIS HAS NOT IMPROVED SIGNIFICANTLY
IN 30YEARS
bull Good Neurological Outcome 01 and 30
Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10
2009 doi101161CIRCOUTCOMES1098895 6
Today Nearly everyone dieshellip
But there is hopehellip
Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits
Importance Of CPR
10-20 of normal blood flow to the heart
20-30 of normal blood flow to the brain
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Objectives
bull Importance of maximizing CPRbull Why compressionventilation ratio 302 bull Complete chest wall recoilbull Danger of hyperventilationbull CPR First vs shock firstbull 1 shock vs 3 shocksbull Minimize delay to shockbull Impedance Threshold Device (ITD) Science
Why I am doing this lecturehellipWhy I am doing this Why I am doing this lecturehelliplecturehellip
A need for changehellip
bull Approximately 350000 persons die from out-of-hospital cardiac arrest each year in North America
bull Survival rate is poor among these patients and most do not survive to hospital discharge
bull New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought
bull Other research suggests that an impedance threshold device (ITD) may improve outcome
CPR in Hollywoodhellip
bull ROSC (Getting a pulse back) 75bull discharged neurologically Intact 67
CPR in Real Life
bull ROSC between 01 and 49ndash 3-7 typical
bull Survival to Hospital Admission 23
bull Survival to Discharge 76ndash THIS HAS NOT IMPROVED SIGNIFICANTLY
IN 30YEARS
bull Good Neurological Outcome 01 and 30
Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10
2009 doi101161CIRCOUTCOMES1098895 6
Today Nearly everyone dieshellip
But there is hopehellip
Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits
Importance Of CPR
10-20 of normal blood flow to the heart
20-30 of normal blood flow to the brain
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Why I am doing this lecturehellipWhy I am doing this Why I am doing this lecturehelliplecturehellip
A need for changehellip
bull Approximately 350000 persons die from out-of-hospital cardiac arrest each year in North America
bull Survival rate is poor among these patients and most do not survive to hospital discharge
bull New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought
bull Other research suggests that an impedance threshold device (ITD) may improve outcome
CPR in Hollywoodhellip
bull ROSC (Getting a pulse back) 75bull discharged neurologically Intact 67
CPR in Real Life
bull ROSC between 01 and 49ndash 3-7 typical
bull Survival to Hospital Admission 23
bull Survival to Discharge 76ndash THIS HAS NOT IMPROVED SIGNIFICANTLY
IN 30YEARS
bull Good Neurological Outcome 01 and 30
Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10
2009 doi101161CIRCOUTCOMES1098895 6
Today Nearly everyone dieshellip
But there is hopehellip
Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits
Importance Of CPR
10-20 of normal blood flow to the heart
20-30 of normal blood flow to the brain
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
A need for changehellip
bull Approximately 350000 persons die from out-of-hospital cardiac arrest each year in North America
bull Survival rate is poor among these patients and most do not survive to hospital discharge
bull New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought
bull Other research suggests that an impedance threshold device (ITD) may improve outcome
CPR in Hollywoodhellip
bull ROSC (Getting a pulse back) 75bull discharged neurologically Intact 67
CPR in Real Life
bull ROSC between 01 and 49ndash 3-7 typical
bull Survival to Hospital Admission 23
bull Survival to Discharge 76ndash THIS HAS NOT IMPROVED SIGNIFICANTLY
IN 30YEARS
bull Good Neurological Outcome 01 and 30
Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10
2009 doi101161CIRCOUTCOMES1098895 6
Today Nearly everyone dieshellip
But there is hopehellip
Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits
Importance Of CPR
10-20 of normal blood flow to the heart
20-30 of normal blood flow to the brain
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
CPR in Hollywoodhellip
bull ROSC (Getting a pulse back) 75bull discharged neurologically Intact 67
CPR in Real Life
bull ROSC between 01 and 49ndash 3-7 typical
bull Survival to Hospital Admission 23
bull Survival to Discharge 76ndash THIS HAS NOT IMPROVED SIGNIFICANTLY
IN 30YEARS
bull Good Neurological Outcome 01 and 30
Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10
2009 doi101161CIRCOUTCOMES1098895 6
Today Nearly everyone dieshellip
But there is hopehellip
Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits
Importance Of CPR
10-20 of normal blood flow to the heart
20-30 of normal blood flow to the brain
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
CPR in Real Life
bull ROSC between 01 and 49ndash 3-7 typical
bull Survival to Hospital Admission 23
bull Survival to Discharge 76ndash THIS HAS NOT IMPROVED SIGNIFICANTLY
IN 30YEARS
bull Good Neurological Outcome 01 and 30
Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-AnalysisComilla Sasson Mary AM Rogers Jason Dahl and Arthur L KellermannCirc Cardiovasc Qual Outcomes 2010363-81 published online before print November 10
2009 doi101161CIRCOUTCOMES1098895 6
Today Nearly everyone dieshellip
But there is hopehellip
Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits
Importance Of CPR
10-20 of normal blood flow to the heart
20-30 of normal blood flow to the brain
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Today Nearly everyone dieshellip
But there is hopehellip
Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits
Importance Of CPR
10-20 of normal blood flow to the heart
20-30 of normal blood flow to the brain
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
But there is hopehellip
Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits
Importance Of CPR
10-20 of normal blood flow to the heart
20-30 of normal blood flow to the brain
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Importance Of CPR
10-20 of normal blood flow to the heart
20-30 of normal blood flow to the brain
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
3 Phase Model
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Cardiac Output During CPR
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
KEY POINT
CPR not PARAMEDICS save lives in most Cardiac Arrests
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Understanding Coronary Perfusion Pressure
Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Understanding Chest Compressions
Compressionbull Increased intrathoracic
pressurebull Compression of heart and
lungs
Decompression (recoil)bull Decreased intrathoracic
pressurebull Refilling of heart and
lungs
Complete chest recoil is criticalComplete chest recoil is critical
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
ROSC Associated with CPP
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Benefit of Continuous Chest Compressions
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Intra-thoracic Pressure and CPR
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
New Cardiac Guidelines (2005)
bull Rate of 100minutebull Depth of 1 12ndash2 inches
ndash (or more in larger people)
bull Complete chest recoil after each compressionbull Ventilation (less is more)
ndash No more than 10 ventilations per minutendash Inspiration phase of no more than 1 second
bull Minimize interruptions in chest compressionsbull Rotate compressors every 2ndash3 minutes to
minimize fatigue
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
2005 to 2010 changeshellip
Component of CPR 2005 ECC recommendations
2010 ECC Recommendations
DEPTH OF COMPRESSION
1 frac12 - 2 inches Greater than 2 inches
RATE 100 MINUTE At least 100 MIN
VENTILATION 8-10 MINUTE 8-10 MINUTE
CHEST RECOIL 100 100
INTURUPTIONS Minimized Less than 10 seconds goal
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Who does good CPR
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Answer NO ONE
Studies showedhellip
bull Chest compressions were not delivered about half of the time (too much ldquohands offrdquo)
bull Most compressions were not deep enough
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Compression DEPTH
bull Target = 38-51 mm with complete releasebull Reality = only 27 achieve target
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
No-Flow Ratio (Interruption of CPR)
bull Target = less than 20bull Reality = 48
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Compression Rate
bull Target = ~100min with complete releasebull Reality = 60min due to ldquoNo Flow Ratiordquo
Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Compression Ratehellip
Percent segmentswithin 10 cpmof AHA Guidelines
31
369
Abella et al 2005 Circulation
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Compression Ratehellip
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Barriers to staying on the chesthellip
bull Pausing for proceduresndash intubation IV pulse check etc)
bull Pausing for rhythm analysis
bull Pausing after shock to await post-shock rhythm
bull Pausing to charge clear and shock
bull Unaware of importance of CPR in ldquobig picturerdquo
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Importance of complete recoil
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Get EVERY Compression Right
Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)
Abella et al 2005 Circulation
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Cerebral Perfusion Pressures and CPR
Abella et al 2005 Circulation
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Current Guidelines for Ventilation
bull CPR with Advanced Airway 8 ndash 10 breathsminute
bull Post-resuscitation 10 ndash 12min
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Compression-Ventilation Ratio
bull Ventilation rate = 12minbull Compression rate = 78minbull Large amplitude waves = ventilationsbull Small amplitude waves = compressionsbull Each strip records 16 seconds of time
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Reality Suckshellip
bull Compression Ventilation Ratio 21bull 47-48 Breaths a minute
47 Nails in a coffin
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Prolonged Ventilations
bull 1048707Ventilation Duration = 436 seconds breathbull 1048707Ventilation Rate = 11 breaths minutebull 1048707 time under Positive Pressure = 80
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Everyone sucks
bull Milwaukeendash Mean Ventilation Rate 37minutendash AFTER 2 months training 22minute
bull Dallas 30minute
bull Tuscan 34minute
bull Chicago gt30minute
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Effect of Vent Rate on CPP
12 RR minute
CPP 234 plusmn 10mmHg
MIP 71 plusmn 07 mmHgmin
20 RR minute
CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin
30 RR minute
CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Aware of importance of CPR
19781975
1980s and 1990rsquos
King CountySeattle Medic One EMS System Data Cobb
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
CPR FIRST
ROSC
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
CPR FIRST BEFORE DEFIB
bull The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent
Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillationJAMA 1999 Apr 7 281
1182-1188
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
CPR IMPROVING DEFIB
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
CPR Whats Next
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
bull 90 of all changes to 2010 ECC are right in the BLS segment
bull Builds on and further enhances the changes and research discussed in the 2005 guidelines
bull COMPRESSIONS are the single most emphasized segment of resuscitation
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Hands Only CPR
bull Single biggest change
bull ldquoHands Only CPRrdquo AKA Compression only CPR for lay persons and non HCP first responders
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
KEY POINT
bull HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
CAB
bull Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
bull This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds
bull This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Pulse Check
bull Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse
bull The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally
bull Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Look Listen and Feel
bull Confusion in Agonal Respirations vs Good Respirations
bull ldquoLook Listen and Feelrdquo de- emphasized
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
CPR Prompts
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Therapeutic Hypothermia
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
New CPR Guidelines
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
Traditional Healthcare Version
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
IMPORTANT POINTIMPORTANT POINT
bull RATERATE
bull DEPTHDEPTH
bull RELEASERELEASE
bull UNINTERRUPTEDUNINTERRUPTED
bull DECREASED DECREASED VENTILATIONVENTILATION
5 KEY5 KEY ASPECTSASPECTS
OFOF GOODGOOD CPRCPR
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar
ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar