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In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College of Medicine
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In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Jan 15, 2016

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Page 1: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

In-hospital Cardiac Arrest: First and foremost,

Chest Compressions

Charles L Campbell MS MDAssociate Professor of Medicine

University of Kentucky College of Medicine

Page 2: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

• No Disclosures

Page 3: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Outline

• IHCA• Hospitals Vary in Outcome• Why• What is recommended• How should it be done• Does it really matter

Page 4: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

IHCA is pretty common…

• ˜200,000 in the US• Survival is 18-20%• There is tremendous

variability among hospitals

• Get with the Guidelines• 135,896– 20% with Ventricular

fibrillation or Ventricular tachycardia

– 64% occur in an ICU

• Median Survival Varies– 8.3% at the lowest

Decile– 31.4 at the highest

JAHA. 2014;3:e000400

Page 5: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

JAHA. 2014;3:e000400

Page 6: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Clinical Feature Odds Ratio P

VT/VF 3.14 <0.0001

PEA 1.06 0.002

Etiology Toxicologic 2.36

ICU 1.60 <0.0001

Monitored 1.72 <0.0001

Comorbid Hepatic insufficiency

0.54 <0.0001

Comorbid Cancer 0.50 <0.0001

Arrest time at night

0.74 <0.0001

Arrest time Weekend

0.86 <0.0001

JAHA. 2014;3:e000400

Page 7: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

JAHA. 2014;3:e000400

Page 8: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

What seems to work?

• Performing ACLS correctly is associated with an improvement in outcome

• MUSC study• Compared guideline

adherence for survivors vs. non-survivors– 75 survivors– 75 non-survivors

• Survivors older and with more cormorbidities

Resuscitation. 2013;85:82-87

Page 9: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2013;85:82-87

Page 10: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2013;85:82-87

Page 11: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2013;85:82-87

Page 12: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2013;85:82-87

Page 13: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

• Each 10% improvement in adherance results in a ˜30% increase in ROSC.

Resuscitation. 2013;85:82-87

Page 14: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

What is Happening

• Weisfeldt and Becker1. Electrical Phase

1. 4 min2. Defibrillation alone

may be effective

2. Circulator Phase1. Chest compressions are

necessary

3. Metabolic Phase4. Stone Heart

JAMA.2002;288:3035-3038

Page 15: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Time course of VF

Page 16: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation. 2005;111:1136-1140 and e294

Page 17: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

J Cardiovascular Magnetic Resonance. 2011;13:17

Hypothermia during VT/VF

Page 18: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

What is Recommended

• Defibrillation• Chest Compressions• Oxygenation• Medications• Procedures

Page 19: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

NEJM 2008;358:9-17

Page 20: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Chest Compressions

• Place patient on a firm surface– Backboard– Deflation of air mattress

• Had in the middle of the chest– 5 cm of depression– Allow complete recoil• Lifting the hand completely of the chest can improve

recoil

Circulation. 2010;122:S685-705

Page 21: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

How Fast

• Rate 100-120 cpm• Deliver >80 per minute– That means minimal interruption

• Duty Cycle– Time between the start of one compression and

the start of the next – Target is 50%– As much time relaxing as compressing

Circulation. 2010;122:S685-705

Page 22: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation. 2005;428-434

Page 23: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation. 2005;428-434

Page 24: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation. 2005;428-434

Page 25: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation. 2012;125:3004-12

• ROC consortium (9 sites)• OHCA in which monitors/defib measured chest compression

rates• 3098 cases analyzed

Page 26: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation. 2012;125:3004-12

Page 27: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation. 2012;125:3004-12

Compression rate vs Compressions Delivered

Page 28: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation Qual Outcomes.2013;6:148-156

Page 29: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Compression Depth

Page 30: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2005;64:363-372

Page 31: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation Qual Outcomes.2013;6:148-156

Page 32: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Recoil Matters…

Page 33: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2006;71:341-351

Page 34: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2006;71:341-351

Page 35: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2006;64:353-362

Page 36: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation Qual Outcomes.2013;6:148-156

Page 37: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation, 2007;73:54-61

Page 38: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation, 2007;73:54-61

Page 39: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation, 2007;73:54-61

Page 40: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2009;80:743-751

Page 41: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Non-Shockable Rhythms

Page 42: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation. 2012;125:1787-94

Page 43: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Circulation. 2012;125:1787-94

Page 44: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Chest Compressions and Defibrillation

Page 45: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2006;71:137-145

Page 46: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2006;71:137-145

Page 47: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

• Survival from OHCA improved after the implementation of a protocol that required 90 seconds of CPR prior to the delivery of a shock via an AED– 24% to 30% – Particularly in those in whom the intial response interval was > 4 min.

JAMA. 1999;281:1182-1188

Page 48: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2008;77:10-15

Page 49: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2008;77:10-15

Page 50: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Resuscitation. 2008;77:10-15

Page 51: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Mechanical CPR?

Page 52: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.
Page 53: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.
Page 54: In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

Conclusions

• Chest Compressions are the cornerstone of resuscitation– Rate– Depth– Recoil– Minimizing Interruptions – Feedback is probably helpful

• In some cases chest compressions aid defibrillation• Mechanical chest compressors have not been

demonstrated to be helpful