Ventilations

ECG


compressions
rhythm check
ECG: v fib
shock given
Arrest transcript
ECG: v tach
Actual arrest transcript: U of C, 2004
Example of CPR recording a real case
Quality of chest compressions: rate
10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 R>120
Chest compression rate (rate per minute)
A
m
o
u
n
t

o
f

t
i
m
e

a
t

a

g
i
v
e
n

r
a
t
e

300


250


200


150


100


50


0


Abella et al, 2005
Clinical importance of chest compression rate
Abella et al, 2005
No ROSC
ROSC
10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 >120
Chest compression rate (per minute)
Mean rate, ROSC group
90 17
Mean rate,
no ROSC group
79 18
210


180


150


120


90


60


30


0

A
m
o
u
n
t

o
f

t
i

What this means: CPR guidelines 2010
New directions in CPR:

Hands-only CPR evidence
suggests mouth-to-mouth may
not be required, especially for
bystander response

New for 2010 guidelines:





Airway-Breathing-Circulation
is now
Circulation-Airway-Breathing

C A B
Pause before shock
4:55 5:00 5:05 5:10
C
o
m
p
r
e
s
s
i
o
n
s










E
C
G

Does CPR quality affect defibrillation?
0
20
40
60
80
100
10.3 10.5-13.9 14.4-30.4

33.2
S
h
o
c
k

s
u
c
c
e
s
s
,

%

90%
10%
55%
64%
Edelson et al, 2006
Pause before a shock it really makes a big difference!
Pre-shock pause, sec
Adenosine triphosphate
How your cells store energy
(charged battery)
Adenosine diphosphate
Depleted energy store
(spent battery)
Visual model for how CPR may restore the heart
First, a little refresher from biology class.
energy
blood flow, oxygen
Visual model for how CPR may restore the heart
0-20 21-40 41-60 61-80 81-100
comp fraction, %
S
u
r
v
i
v
a
l

t
o

d
i
s
c
h
a
r
g
e
,

%

0











1
0











2
0









3
0

Compression fraction amount of compressions given to a patient
Christenson J et al, Circ 2009
poor survival with lowest
compression fraction in OHCA

40

32

24

16

8

0
1 2 3
CPR duration, min
C
o
r
o
n
a
r
y

a
r
t
e
r
y


B
l
o
o
d

p
r
e
s
s
u
r
e

ICCM, 2005
2 inches vs 1.5 inches
Survival:

100%



15%
The DETAILS of CPR delivery makes a big difference
More on chest compression depths
What is the role of chest compression depth during out-of-hospital
cardiac arrest resuscitation?

Ian G. Stiell, MD et al Critical Care Medicine 2012
20 30 40 50 60
0




1
0
%




2
0
%




3
0
%

s
u
r
v
i
v
a
l

compression depth
>2 inches
Aufderheide et al, 2004
Study of paramedic ventilations:
mean ventilation rate was 30 per minute!
(AHA recommended rate 8-10 per minute)

first group: 37 4 after retraining: 22 3
Does the quality of ventilations matter?
Slower
breaths
Faster
breaths
Aufderheide et al, 2004
Study of paramedic ventilations:
mean ventilation rate was 30 per minute!
(AHA recommended rate 8-10 per minute)

first group: 37 4 after retraining: 22 3
Does the quality of ventilations matter?
Slower
breaths
Faster
breaths
These rapid ventilations were tested in animals placed
in cardiac arrest and it KILLED ALL THE ANIMALS

The publication was entitled DEATH BY HYPERVENTILATION

May represent fatiguing (rescuer getting tired)
Other challenges to CPR performance: fatiguing during compressions
30 60 90 120 150
120
115
110
105
100
95
90
85
80
0
Time (sec)
C
C

r
a
t
e

(
c
o
m
p
s

p
e
r

m
i
n
)

Sugerman et al, Resusc 2009
Other challenges to CPR performance: fatiguing during compressions
30 60 90 120 150
Time (sec)
C
C

d
e
p
t
h

(
m
m
)

Sugerman et al, Resusc 2009
Other challenges to CPR performance: fatiguing during compressions


55

50

45

40

35

0