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Presenter Disclosure Information
• Colby Rowe
• FINANCIAL DISCLOSURE:
• No relevant financial relationship exists
• No Unlabeled/Unapproved Uses in Presentation
Blood flow During CPRwith Under-compression
0
Normal Blood Flow
Blood Flow During CPR
100%
25%
0%
50%
75%
Blood flow During CPR with Under-compression and
Hyperventilation
0
Normal Blood Flow
Blood Flow During CPR
100%
25%
0%
50%
75%
Blood flow During CPR with Under-compression, Hyperventilation and
Long Pre-shock Pauses.
100
25
0
50
75Normal Blood Flow
Blood Flow During CPR
Ventilation, defibrillation, intubation, IV, drugs, etc.
100%
25%
0%
50%
75%
Coronary Perfusion pressure (Ao diastolic - RA diastolic)Coronary Perfusion pressure (Ao diastolic - RA diastolic)
Chest Compressions and CPPChest Compressions and CPP
Berg, Circ 2001
Shock Success by Compression Depth
Sh
ock
Su
cc
ess
, Pe
rcen
t
Compression Depth, Inches
n=10 n=5n=17n=15
P=0.008
Dana P. Edelson , et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation, Volume 71, Issue 2, 2006, 137 - 145
Effect of Compression Depth on Survival
0
5
10
15
20
25
30
35
1 2 3 4
% A
dmitt
ed A
live
Compression depth quartile
Sister Out-of Hospital data n= 284
<1.2 inch 1.2 to 1.3 inch 1.3 to 1.6inch >1.6 inch
Diagram of preshock, postshock, and perishock pause.
Cheskes S et al. Circulation. 2011;124:58-66
Copyright © American Heart Association, Inc. All rights reserved.
Association between pre-shock pause and shock success.
Cases are grouped by pre-shock pause in 10 s intervals. Note that longer pre-shock pauses are significantly associated with a smaller probability of shock success.
The quality of CPR prior to defibrillation directly affects clinical outcomes.
Specifically, longer pre-shock pauses and shallow chest compressions are associated with defibrillation failure.
Pre-Shock Pause Duration and Defibrillation Success
15
Dana P. Edelson , et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation, Volume 71, Issue 2, 2006, 137 - 145
Peri-Shock Pause and SurvivalPre-shock
pause, secs.
<10 secs.
10–19 secs.
≥20 secs.
Survival, %
35.1 35.5 25.1 P=0.02
Post-shock pause, secs.
<10 secs.
10–19 secs.
≥20 secs.
Survival, %
31.8 30.8 22.7 P=0.06
Peri-shock pause, secs.
<20 secs.
20–39 secs.
≥40 secs.
Survival, %
32.6 31.9 20.3 P=0.01Cheskes S, et al; Resuscitation Outcomes Consortium (ROC) Investigators. Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation. 2011 Jul 5;124(1):58-66.
Consecutive Case Consecutive Case Ventilation Ventilation RateRate
(breaths/min)(breaths/min)
Ventilation Ventilation DurationDuration
(secs./breath)(secs./breath)
% Positive % Positive PressurePressure
Group 1Group 1
Mean Mean ± SEM± SEM37 37 ± 4*± 4* 0.85 0.85 ± .07*± .07* 50 50 ± 4± 4%%
Group 2Group 2
Mean Mean ± SEM± SEM22 22 ± 3*± 3* 1.18 1.18 ± .06*± .06* 44.44. 8.2 8.2%5 %5
±±* p < 0.05
Aufderheide T, et al. Hyperventilation-Induced Hypotension During Cardiopulmonary Resuscitation. Circulation. 2004; 109: 1960-1965.
Porcine Survival Study
Breaths/MinuteBreaths/Minute O2/CO2O2/CO2 Survival RateSurvival Rate
7 Pigs =7 Pigs =12 BPM12 BPM 100% O2100% O2 6/7 (86%)6/7 (86%)
7 Pigs = 7 Pigs = 30 BPM30 BPM 100% O2100% O2 1/7 (14%)*1/7 (14%)*
7 Pigs = 7 Pigs = 30 BPM30 BPM*P < 0.05*P < 0.05
95% O2/5% CO295% O2/5% CO2 1/7 (14%)*1/7 (14%)*
Aufderheide T, et al. Hyperventilation-Induced Hypotension During Cardiopulmonary Resuscitation. Circulation. 2004; 109: 1960-1965
Time (mins)
% rS
O2
Illustration of the Impact of Manual & Automated Chest Compression on Cerebral Perfusion in Two Patients
Automated CPR (patient 1) Manual CPR (patient 2)
0
20
40
60
80
rSO
2%
Manual CPR Automated CPR
Impact of automated CPR on rSO2
*
* p= <0.0001 Mann-Whitney Test, (Manual CPR n=22, Automated CPR n=12)
Quality of CompressionsAHA Standards
Stapleton E. Quality of CPR During Transport. JEMS 1991Sep;16(9):63-4, 66, 68
Manual CPR Automated CPR
*
ROSC = Return of Spontaneous Circulation lasting > 20 mins. *p < 0.05 using Fischer's Exact test. (Manual CPR n=44, Automated CPR n=20)
% R
OSC
Automatic CPR leads to higher Return Spontaneous Circulation Following Cardiac Arrest
H's T's
Hypoxia Toxins
Hypovolemia Tamponade (cardiac)
Hydrogen ion (acidosis) Tension pneumothorax
Hypo-/hyperkalemia Thrombosis, pulmonary
Hypothermia Thrombosis, coronary
What can Prehospital Providers do for H’s and T’s anyway?
• Decompress Tension Pneumothorax• Pericardiocentesis• Volume• Toxicology Antidotes• Treatment of Hyper/Hypokalemia
• Early notification• “Trauma system strategy”• “12 Lead ECG strategy”
H’s and T’s Process
1. Systematically consider - based on the presenting problem
– Trauma = hypovolemia, tension pneumothorax, tamponade
– History is a good first step!
2. How to recognize?– Tamponade = Ultrasound
identification
3. How to treat?– Tamponade = Pericardiocentesis
PotentialUsefulness of Ultrasound
• Pneumothorax, • Tension Pneumothorax• Pericardial Tamponade• Hypovolemia• Cardiogenic Shock• Pulmonary Embolus• … and more