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Cardiac Arrest, Hypothermia and Resuscitation Science

Lecture 2: CPR the foundation of resuscitation care




Benjamin S. Abella, MD MPhil




Clinical Research Director
Center for Resuscitation Science
Department of Emergency Medicine
University of Pennsylvania




Coursera
July 2012

An introductory course for the educated lay public and health care providers




Dr. Abella: conflicts of interest disclosures


Employment: University of Pennsylvania

Research funding: National Institutes of Health
Philips Healthcare
Medtronic Foundation

Consulting: Velomedix, Inc.
HeartSine Technologies

Volunteer: American Heart Association Sudden Cardiac Arrest Association

No equity or intellectual property related to resuscitation science











Refresher from Lecture 1: What is cardiac arrest?
Without any blood flow to the lungs or brain,
the victim of cardiac arrest is technically
dead and appears lifeless

(For brief minutes, may have gasping or
seizure activity)

The immediate actions required to restore
blood flow:

1. Cardiopulmonary resuscitation (CPR)
2. Electrical defibrillation

Both of these can be done by the lay public




Refresher from Lecture 1: Survival from cardiac arrest is highly variable
Survival from cardiac arrest depends on where you live

From a large research study in 2008, showing survival to
hospital discharge for victims of cardiac arrest:
S
u
r
v
i
v
a
l

t
o


d
i
s
c
h
a
r
g
e


Dallas Pittsburgh Portland Seattle

4.5%
7.0%
10.6%
16.3%
Nichol et al, JAMA 2008
Why is survival so variable?
CPR is key to variable survival

In a given community:

Lay public factors:

How many people know CPR?
How many people deliver CPR?
What is the quality of the CPR?

Professional factors:

What is the time to professional CPR delivery?
What is the quality of professional CPR?




What do we know about CPR training among the lay public?
Many organizations offer CPR training:

American Heart Association
American Red Cross
local training organizations
Millions trained each year, but most are health professionals
Performing re-certification
Imagine a map showing areas with
High or low CPR training rates

No such map exists!
What do we know about CPR delivery among the lay public?
Approx. 26-38% of cardiac arrest victims receive layperson CPR


In one large study, striking difference between private / public location


Home/private


public


Rate of bystander CPR


0 10 20 30 40 50


26%
45%
Weisfeldt et al, 2011


The quality of CPR makes a big difference in survival
Study of CPR in New York City

Lay public CPR was observed by
arriving EMS professionals

CPR quality was judged as high
or low quality








Victims receiving high quality CPR were FOUR TIMES more likely
To be resuscitated

Gallagher et al, 1995



Detailed study by Ken Nagao et al (Japan)

In Japan, some regions had emergency dispatch
protocols that INCLUDED breaths, and some that
OMITTED breaths



Should we provide breaths during CPR?
Important to note: study of bystander
CPR provided by the public, and the
CPR wasnt measured.


Investigators asked: did it matter?





1 2 3 4 5 6 7 8 9 10 11 12 13 14 15



80

60

40

20

0

3
0

d
a
y

s
u
r
v
i
v
a
l
,

%

Minutes from bystander CPR to defibrillator
Chest compressions only
standard CPR with breaths
SOS-KANTO et al, 2007
Breaths during public CPR dont help, and they may hurt
Better survival with only
chest compressions, no
matter how long it took to
respond!
Bystander
contacted
9-1-1
survival to hospital discharge
11.5% 14.4%
standard CPR (n=960) chest compression alone (n=981)
The DETAILS of CPR delivery makes a big difference


CPR with chest compression alone or with rescue breathing

T Rea et al, 2010

Berg et al, 2001
B
l
o
o
d

p
r
e
s
s
u
r
e

Time
= chest compression
Why pauses in chest compressions may be a bad thing
Berg et al, 2001
B
l
o
o
d

p
r
e
s
s
u
r
e

Time
= chest compression
Few compression pauses lead to better blood flow