2022 high performance cpr update

HIGH
PERFORMANCE CPR
UPDATE
ACCESS – BT – 2022 01 HIGH PERFORMANCE CPR UPDATE

The
Problem
Approximately 350,000
persons die from out-of-
hospital cardiac arrest
each year in North
America. (2018 AHA
Data)
ACP /ACCESS had 236
non-traumatic “working
codes” in 2020.

But there
is hope…
HOWARD SNITZER, 59,
SURVIVED 96 MINUTES OF CPR
WITH NO NEURO DEFICITS.

Howard is not the only one…
2016 Study
◦ 86 cases of good outcome
◦ Most common causes were MI, PE, and Hypothermia (only 19%)
◦ Median CPR time 75 minutes
◦ 74% of arrests were witnessed
◦ 96% of patients had good CPR
◦ 83% survived > 1 year
◦ 73% had good neuro outcome (CPC score 1 or 2)
◦ What did they all have in common? 96% of patients had good CPR
Youness, H., Al Halabi, T., Hussein, H., Awab, A., Jones, K., & Keddissi, J. (2016). Review and
Outcome of Prolonged Cardiopulmonary Resuscitation. Critical Care Research and Practice,
2016, 7384649. https://doi.org/10.1155/2016/7384649

What if I said
resuscitation is
Kung Fu?

Why I am doing this lecture….
“Kung Fu” is “Time and Effort”
Kung (功), can mean skillful
work, hard training, or
endeavor.
Fu (夫), means time spent.
So, how is your resuscitation “Kung Fu”?

How we can improve our
Resuscitation Kung Fu
Put in Time
◦ Train more often than required
◦ Bi-Annual is not enough
◦ Is yearly enough?
◦ Perhaps “high frequency/Low intensity”
training?
◦ Perhaps training among yourselves?
Put in Effort
◦ More than checking a box….
◦ What type of training works?
◦ What type of feedback works?
◦ Leaders…lead the way…

How are we
doing?
HOW IS OUR “TIME” AND “EFFORT” PAYING OFF?

Where we were…
2013
Adult 203 medical cardiac arrests.
◦ 145 suspected cardiac.
39% ROSC
◦ 50% ROSC with Bystander CPR
2015
Adult 224 medical cardiac arrests.
◦ 178 suspected cardiac.
50% ROSC (+11%)
◦ 60% ROSC with Bystander CPR
(+10%)

2018 vs 2019 vs. 2020 CARES Data
ACCESS

2018 vs 2019 vs. 2020 CARES Data
National (U.S.)

The numbers that count….
US Data
13, 5059 total non-trauma Patients
(4244 Trauma Patients)
◦ GOAL: CPC score of 1 or 2
◦ 48543 Witnessed (Bystander) :
◦ CPC 1 or 2: 5,250 (10.8% )
◦ 65503 Unwitnessed
◦ CPC 1 or 2: 1,992 (3 % )
◦ 16792 Witnessed by First Responders
◦ CPC 1 or 2: 2,048 (12.1 % )
◦ 9,290 Total with CPC score of 1 or 2
◦ 7.1 % Quality Survival
5% increase: 6,500 patient difference
ACCESS Data
229 total non-trauma Patients
( 7 Trauma)
◦ GOAL: CPC score of 1 or 2
◦ 88 Witnessed (Bystander) :
◦ CPC 1 or 2: 16 (18.1%)
◦ 120 Unwitnessed
◦ CPC 1 or 2: 3 (0.2%)
◦ 21 Witnessed by First Responders
◦ CPC 1 or 2: 3 ( 14.2%)
◦ 22 Total with CPC score of 1 or 2
◦ 9.6 % Quality Survival
A 5% improvement = 11-12 patient
difference

Why does CPR
work?
SCIENCE BEHIND HIGH PERFORMANCE CPR

Resuscitation
Arsenal
CPR
Defibrillation
Advanced Airways
IV’s and IO’s
Epinephrine
Antiarrhythmics
Sodium Bicarbonate
Other WIZ-BANG! Paramedic stuff

KEY
POINT:
CPR, NOT PARAMEDICS,
SAVE LIVES IN MOST
CARDIAC ARRESTS

HP-CPR makes all the “Para-Magic”
work better.
Anti- Arrythmics

How did we get
better?
INTRO TO HIGH PERFORMANCE CPR

What are our metrics of performance?
RATE
◦ 100-120
◦ 110 ideal
DEPTH
◦ 2”
RELEASE/RECOIL
◦ Complete
UNINTERRUPTED
◦ 3 second goal
◦ 80% compression fraction
DECREASED VENTILATION
◦ 6-10/min
5 KEY
ASPECTS
OF
GOOD
CPR!

Key
ingredients to
our recipe
RATE
•Improving Perfusion through 220 continuous compressions
DEPTH
•Improving Performance with Feedback and peer
monitoring
RELEASE/RECOIL
•Improving Performance with Feedback and peer
monitoring
UNINTERRUPTED
•Reducing interruptions via assignments and positions
•Reducing interruptions via “Calling 200”
•Reducing interruptions via Hovering
•Reducing interruptions via pre-charging
DECREASED VENTILATION
•Decreasing ventilation rate/volume with Feedback and
peer monitoring
•Improving ventilations with 2 person methods

Compression…..
Increases intrathoracic pressure
Ejects Blood from the heart and lungs
“Good” compression increases cardiac
output (CO) and blood pressure
“Bad” Compressions hinders it
Tissue Perfusion
Remember, you are not just compressing the
heart, but the but the whole chest.

5 sec
80
160
mmHg
Time (sec)
40
120
0
Coronary Perfusion Pressures
Cerebral Perfusion
Pressures
No Cerebral
Perfusion
Single rescuer performing 30:2 with realistic 16 sec.
interruption of chest compressions for MTM ventilations
Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525

0
5 sec
80
160
mmHg
Time (sec)
40
120
Coronary Perfusion Pressures
Continuous Cerebral Perfusion Pressures
Single rescuer performing
continuous chest compressions
Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525
Perfusion with continuous compressions

New Data on
CPR Rates…
Multiple studies show that
“excessive” rates are as significant a
problem, particularly in pediatric
patients. (Hunt et al., 2018)
More common in healthcare
providers than lay public. (Lin et al.,
2020)
CPR Feedback and CPR Coaches
(combined) may be of substantial
benefit in getting our rates under
control.

Dec 2021
Mean rate: 132/Minute

December 2021
A tale of two compressors….

Wrapping up
Our goal:
◦ 100-120 a minute
◦ 110 target
◦ Too fast or Too Slow lowers CPR output
The first 10 minutes is the most vulnerable
to poor performance
◦ Tend to be too fast

Edelson DP et al., Resuscitation 2006;71;137-145

Wrapping up
Our goal:
◦ 2-2.4 inches
to poor performance
◦ Corresponds with HR variability

Blood Flow during CPR
10-20% OF NORMAL BLOOD FLOW TO THE
HEART
20-30% OF NORMAL BLOOD FLOW TO THE
BRAIN

Understanding Chest Compressions
Compression
Increased intrathoracic
pressure
Compression of heart and lungs
Decompression (recoil)
Decreased intrathoracic
pressure
Refilling of heart and lungs
Complete chest recoil is critical

Poor Recoil = Increased Intrathoracic
Pressure

KEY POINT
Complete
Chest
Recoil is
essential
to survival

Wrapping up
Our goal:
◦ Complete Recoil
to poor performance
◦ Corresponds with HR variability

“This is where ‘Time’ and ‘Effort’ come together as a team”

Compression Fraction
The chest compression fraction (CCF) is the
proportion of time spent performing chest
compressions during arrest.
The goal is 80% of every minute to be
compressing the chest (80% CCF)

Wrapping up
Our goal:
◦ On the chest as rapidly as possible after cardiac
arrest is determined
◦ Pauses < 10 seconds
◦ Ideally less than 3 seconds
to poor performance

Over Ventilation = Increased
Intrathoracic Pressure
“The physiological penalty of assisted ventilation, with
its frequently incorrect rate and duration, is a persistently
positive intrathoracic pressure throughout the
decompression phase of CPR. This decreases cardiac
preload, cardiac output, and hinders right ventricular
function.”
- Bobrow BJ, Ewy GA. Ventilation during resuscitation efforts for out-of-hospital primary
cardiac arrest. Curr Opin Crit Care. 2009;15(3):228–233.

Ventilation control 6-10 times a minute.

Two Handed Seal: Two
Thumbs up method

Low Pressure
Keep it in the green

Focus on Compressions not
Ventilation!!!

Better, but still not there….

Wrapping up
Our goal:
◦ Less Ventilations: 6-10/minute
◦ Better Ventilations
◦ Low Volume (1 handed underhanded squeeze)
◦ Low Pressure < 20 cmH2O
to poor performance

Zoll Dashboard Display
Rate indicator
Perfusion
performance
indicator
Depth indicator
Release
ETCO2
CPR Quality

Rate indicator
Depth indicator
CPR Timer

CPR Coach
2018 John Hopkins Study noticed that teams
focused on HP CPR missed underlying causes
due to cognitive overload.
They proposed a new role, the CPR “COACH” to
off load management of the team from the
“Code Commander” (Team Leader).
The goal of the CPR coach is to ensure that the
compressor will provide deliver exquisite CPR
and to cognitively unload the Team Leader such
that they can focus on following the Advanced
Life Support algorithm and diagnosing and
treating the underlying cause.

So Who does this?
Anyone not directly involved in HP CPR
Ideally a dedicated role.
An EMS BC? Engine Captain? Second EMS provider?

Wrapping up
Our goal:
◦ Use feedback on every code
◦ Personal Feedback (CPR coaching)
to poor performance. BLS Leadership is
crucial.

Ada County’s High-Performance Model of
CPR

Disclaimer!!!
There are many takes on High Performance
CPR, this is just “ours” that fits “our” system.
◦ It is not perfect
◦ It is not the only way
The science is always changing, follow the
science, not the loudmouth (me).

Positions for ACP/A.C.C.E.S.S. High
Performance CPR - BLS
COMPRESSIONS
 Position1/2 (alternating)
 Performs high-quality
compressions•:
 Hand placement on
lower half of sternum
 200 compressions @
110/minute
 Approximately 2 minutes
per cycle
 Complete recoil after each
compression
 Calls “180” and counts
down.
 Compresses at least 2
inches (5 cm)
 Complete Recoil
 “Hovers: when alternating
and during pauses
 Peri-shock pauses to
under 3 seconds.
AIRWAY
 Position 1/2
(alternating) ventilates at a
rate of 1 breath every 6-10
seconds (6-10/minute)
 Delivers breaths
asynchronously with
compressions with short
“upstroke” ventilations
 Position 3 establishes a
good 2 handed seal and:
 Maintains proper
head/airway position
including ear to sternal
notch
 Inserts adjunct as needed
based on scope of practice
without stopping
compressions.
 Visible chest rise with
each breath
TEAM LEADER/Code Commander
Every resuscitation must have a team leader
 Assigns roles PTA ,  Makes treatment decisions  Monitors performance
 Assumes responsibility for roles not assigned.  Communicates status on radio and
in person
 Should be highest certification.  Often airway position (3).

Positions for ACP/A.C.C.E.S.S. High
Performance CPR – BLS + ALS Intergration
COMPRESSIONS
 Position1/2 (alternating)
 Performs high-quality
compressions•:
 Hand placement on
lower half of sternum
 200 compressions @
110/minute
 Approximately 2 minutes
per cycle
 Complete recoil after each
compression
 Calls “180” and counts
down.
 Compresses at least 2
inches (5 cm)
 Complete Recoil
 “Hovers: when alternating
and during pauses
 Peri-shock pauses to
under 3 seconds.
AIRWAY
 Position 1/2
(alternating) ventilates at a
rate of 1 breath every 6-10
seconds (6-10/minute)
 Delivers breaths
asynchronously with
compressions with short
“upstroke” ventilations
 Position 3 establishes a
good 2 handed seal and:
 Maintains proper
head/airway position
including ear to sternal
notch
 Inserts adjunct as needed
based on scope of practice
without stopping
compressions.
 Visible chest rise with
each breath
Intervention Medic
 IO/IV Access Administer Medications  May run manual defibrilator
Communicates with team
ALL INTERVENTIONS SECONDARY TO BLS TEAM
EFFORTS
TEAM LEADER/Code Commander
Every resuscitation must have a team leader
 Assigns roles PTA ,  Makes treatment decisions  Monitors performance
 Assumes responsibility for roles not assigned.  Communicates status on radio and
in person
 Should be highest certification.  Often Intervention Medic.

Wrapping Up
CPR Takes priority
EMTs own the success of
CPR
Medics work around the
CPR team, not over or
through them.

Lucas 3
Compression Rate at
111/min
Audible Prompts
(Chimes)
◦ 2-minute pause
warning
◦ Respiratory Chime

Two Step Lucas Placement
The LUCAS should be placed in a twostep
procedure to maximize the compression fraction.
◦ Step 1: Back plate can be placed at the 4-minute rhythm
check or any 2-minute check thereafter.
◦ Step 2: Chest piece should be placed at the appropriate
rhythm check 2minutes after the back plate is placed.
If placement of the Lucas is delayed or
complicated, return immediately to manual CPR.

Lucas Pauses
16.8
Sec
20.7
Sec

Pro-Tips for LUCAS placement
Placement is critical. Most “injuries” occur from the
LUCAS slipping out of place.
Keep a sharpie handy to mark LUCAS placement, so
watch for “migration” or “Walking” of the LUCAS.
Watch out for clothes bundling jamming up the
locks
Place the neck strap tightly

“Mechanical chest compression with LUCAS device
does not improve clinical outcome in out-of-hospital
cardiac arrest patients” (2019)
Meta Analysis of 6 different studies and 8,501 patients.
Conclusion: “The synthesis of available evidence does not support that mechanical
chest compression with LUCAS device improves clinical outcome in out-of-hospital CA
patients compared with manual chest compression.”
Mechanical CPR Manual CPR
ROSC 33.3% 33.0%
Hospital Admission 22.7% 24%
Survival to Discharge 8.6% 10.7%
30 Day Survival 7.5% 8.5%

“Out-of-hospital cardiac arrest outcomes with
“pit crew” resuscitation and scripted initiation
of mechanical CPR” (2018)
444 patients in the A-TCEMS system. ½ received manual, ½ received
LUCAS.
“Conclusions: In this EMS system with a standardized, "pit crew"
approach to OHCA that prioritized initial high-quality initial resuscitative
efforts and scripted the sequence for initiating mechanical CPR, use of
mechanical CPR was associated with decreased ROSC and decreased
survival to discharge.”
“In the propensity matched analysis (n = 176 manual CPR; 176
mechanical CPR), both ROSC (38.6% vs. 28.4%; difference: 10.2%; CI:
0.4% to 20.0%) and survival to discharge (13.6% vs. 6.8%; difference:
6.8%; CI: 0.5% to 13.3%) remained significantly higher for patients
receiving manual CPR.”

So, are there any advantages
of the LUCAS?
Consistency
Safety
Shorter Pauses after it is placed

Future of the Lucas?
Only after 6-10 minutes?
Transport Only?
Limited Resources?
Rapid Transport of SCA?

2-step LUCAS
Placement
Be mindful of the
pauses
Don’t Rush to the
LUCAS

2022 high performance cpr update

2022 high performance cpr update

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2022 high performance cpr update