1 / 53

Presenter Disclosure Information

Presenter Disclosure Information. Gordon A. Ewy, M.D. Photo Finish: Where Do We Stand with Hands Only CPR? FINANCIAL DISCLOSURE: One of the Principle Investigators of a “ HeartRescue Project” grant to the University of Arizona from the Medtronic Foundation. Center for Resuscitation Science.

kasen
Download Presentation

Presenter Disclosure Information

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Presenter Disclosure Information • Gordon A. Ewy, M.D. • Photo Finish: Where Do We Stand with Hands Only CPR? • FINANCIAL DISCLOSURE: • One of the Principle Investigators of a “HeartRescue Project” grant to the University of Arizona from the Medtronic Foundation

  2. Center for Resuscitation Science HeartRescue Partners

  3. Presenter Disclosure Information • Gordon A. Ewy, M.D. • Photo Finish: Where Do We Stand with Hands Only CPR? • FINANCIAL DISCLOSURE: • One of the Principle Investigators of a “HeartRescue” grant to the University of Arizona from the Medtronic Foundation • UNLABELED/UNAPPROVED USES DISCLOSURE: • When implemented, “Compression-only CPR” was not AHA Guidelines approved

  4. Photo Finish: Where Do We Stand with Hands Only CPR? Gordon A. Ewy, M.D. Professor of Medicine (Cardiology) Director University of Arizona Sarver Heart Center University of Arizona College of Medicine Tucson, AZ USA THE UNIVERSITY OF ARIZONA Sarver Heart Center

  5. ECCU 4:45 to 5:35 PM 9/13/12Gordon Ewy MD & Tom Rea, MD • All agree that “Hands only CPR” (CPR without breaths) has been a game-changer. • Question: “Is it only for lay providers or is it appropriate for professional rescuers as well?” • Question: “Is it right for all cardiac arrest victims or just selected patients?”

  6. Photo Finish: Where Do We Stand with Hands Only CPR? • “Is it only for lay providers or appropriate for professional rescuers as well?” • I will present evidence to support my contention that for “primary cardiac arrest”, CO-CPR or Hands Only CPR is not only for lay providers, but for professional rescuers as well!

  7. Survival rates of OHCA averaged 7.6% and were unchanged for 30 years--from 1978 to 2008 1992 1980 1986 2000 2005 1974 2000 1992 Sasson, C. et al Circ Cardiovasc Qual Outcomes 2010;3:63

  8. “Utstein” Guidelines for Reporting Cardiac Arrest Utstein “2” Report all cardiac arrests Jacobs, I et al. Circulation 2004;110:3385-3397 Utstein “1” Report VF arrests Chamberlain, D. et al. “Utstein 1” Resuscitation 1991;22:1-26 Cummins R.O. et al. “Utstein 1” Circulation 1991;82:960-975

  9. The survival rate of patients with OHCA in VF is a better indicator of effectiveness • Average published survival rate of VF was 17.7% • Unchanged for 23 years (1980 to 2003) Rae et al. Resuscitation 2004;63:17-24

  10. In our animal model of OHCA due to VF, (Primary Cardiac Arrest) survival was dramatically better with CO-CPR than no CPR until “simulated EMS arrival” 100% 80% 40% 20% 0% 73% Percent 24-48 Hour Neurologically Normal Survival 13% CO-CPR No CPR University of Arizona Sarver Heart Center CPR Research Group Circulation 1993;88:1907-1915

  11. Accordingly, we have advocated CO-CPR for the past 2 decadesInitially because it was better than no bystander CPR, and only about25% of patients with OHCA werereceiving bystander CPR Berg, R.A. et al. Circulation 1993;88:1907 Ewy, G.A. N Engl J Med. 2000;342:1599-1601 Kern, K.B. et al. Resus 2005;64:2005

  12. To our surprise, in our physiologic laboratory, survival was the same with CO-CPR and “ideal” Guidelines CPR 100% 80% 60% 40% 20% 0% 73% 70% Percent 24-48 Hour Neurologically Normal Survival CO-CPR “Ideal” Std-CPR University of Arizona Sarver Heart Center CPR Research Group

  13. We continued to advocate CO-CPR in the 1990s as it was as effective as “ideal” AHA Guidelines CPR Berg, R.A. et al. Circulation 1993;88:1907 Ewy, G.A. N Engl J Med. 2000;342:1599-1601 Kern, K.B. et al. Resus 2005;64:2005

  14. Standard “ideal” CPR 15:2 (2 seconds per breath) 4 sec Ewy, GA. Circulation 2005

  15. Soon after 2000 AHA Guidelines were published Single Rescuer CPR Lay Public: 16 + 1 seconds Assar D, Chamberlain D, Colquhoun M, Donnelly P Handley AJ, Leaves S, Kern KB. Resuscitation. 2000;45:7-15.

  16. CO-CPR equivalent to “ideal CPR”: 4 sec interruption of each set of chest compressions for MTM ventilations 71% compressions 19% ventilations What about “realistic CPR”: 16 sec interruption of each set of chest compressions for MTM ventilation? 42% compressions 58% ventilations ECG: VF

  17. Outcomes During Simulated Single Lay Rescuer Scenario of OHCA from VF 100% 80% 60% 40% 20% 0% P < 0.003 80% 24-Hour Neurological Normal Survival (percent) 13% CC Only CPR Realistic 2:15 CPR Kern, Hilwig, Berg, Sanders, Ewy. Circulation 2002; 105: 645-649

  18. But don’t you need “rescue breathing” for primary cardiac arrest?

  19. We announced our intention Resuscitation; 2003; 58: 271 We explained our rational We explained our rationale Circulation 2005; 111: 2134-2142

  20. In 2003, CO-CPR was advocated for all bystanders of OHCA in Tucson, Arizona

  21. Statewide CO-CPR Campaign in Arizona in 2004 Flyers sent to households in utility bills Free CO-CPR training Training Kits sent to all 6th to 12th grade schools Newspaper articles Radio and TV spots Celebrity endorsements

  22. 2005 AHA CPR Guidelines Changed bystander CPR from 2:15 to 2:30 Based on “Consensus of Experts” Disappointed when 2005 Guidelines did not endorse CO-CPR

  23. 160 5 sec 120 mmHg 80 40 Time (sec) Single rescuer performing 30:2 with realistic 16 sec. interruption of chest compressions for MTM ventilations No Cerebral Perfusion Cerebral Perfusion Pressures Coronary Perfusion Pressures 0

  24. 160 5 sec 120 mmHg 80 40 Time (sec) Single rescuer performing continuous chest compression CPR Single rescuer performing continuous chest compressions Continuous Cerebral Perfusion Pressures Coronary Perfusion Pressures 0

  25. Ewy GA, et al Circulation 2007;116:2525

  26. Bystander CPR for OHCA in Arizona (2005 to 2010) 5,272 adult presumed cardiac arrests not observed by EMS 779 excluded; non-lay or occurred in medical facility 4,493 adult not observed by EMS 2 excluded; missing bystander data 2,941 no bystander resuscitation 1,550 bystander resuscitation 18 excluded unidentified bystander CPR technique 1,532 Bystander CPR 857 CCO- CPR 675 Conventional CPR 4,415 comparison to survival to hospital discharge after cardiac arrest (10 missing outcomes, 1 missing rhythm data, 47 missing response intervals

  27. Survival after Bystander CPR for OHCA in Arizona (2005 to 2010) Compression Only CPR Advocated and Taught All OHCA Witnessed/Shockable 35% 30% 25% 20% 15% 10% 5% 0% 33.7% AOR 1.6 (95% CI, 1.08-2.35) P < 0.001 23 years 17.7% Survival to Hospital Discharge 30 years 7.6% 17.7% 13.3% 7.8% Std-CPR CO-CPR Std-CPR CO-CPR Bobrow, et al. JAMA 2010:304:1447-1454

  28. ORIGINAL CONTRIBUTION JAMA Chest Compression-Only CPR by Lay Rescuers and Survival From Out-of-Hospital Cardiac Arrest Bobrow, B.J. et al. JAMA October 6, 2010;304:1447-1454

  29. Is there other evidence in man that CO-CPR improves survival?

  30. New England J Medicine 2010;363:423 Survival (shockable rhythm) to hospital discharge : CC alone 31.9% vs. CC with RB 25.7% (P= 0.09) Close to 33.7% presented in Arizona

  31. New England J Medicine 2010:363;434 Overall, this study lends further support to compression-only CPR

  32. Randomized Trials of DA-CPRA Meta-analysis Hüpfl et al. Lancet. 2010;376:1552-1557 Dispatch Assisted bystander CO-CPR improved survival

  33. ECCU 4:45 to 5:35 PM 9/13/12Gordon Ewy MD & Tom Rea, MD • All agree that “Hands only CPR” (CPR without breaths) has been a game-changer. • Is it only for lay providers or is it appropriate for professional rescuers as well?

  34. 2010 AHA Guidelines for CPR and ECC Major step forward for AHA Guidelines decades of emphasis on “rescue breathing”) Circulation 2010;122: October 16th

  35. 2010 AHA Guidelines for CPR and ECC Circulation 2010;122: October 16th

  36. 2010 AHA Guidelines for CPR and ECC 30:2 No data it improves survival in patients with primary cardiac arrests Circulation 2010;122: October 16th

  37. 2010 AHA Guidelines“Improved but not Optimal”* • “Hands Only” CPR for untrained individuals • *Recommend training for all to perform 30:2 compressions: ventilations

  38. Ventilation: Can Anyone Perform to the Guidelines? Single Rescuer CPR Lay Public: 16 + 1 seconds Assar et al. Resuscitation 2000; 45:7-15 Medical Students: 14 + 1 seconds Heidenreich et al. Resuscitation 2004;62:283-289 Paramedics: 10 + 1 seconds Higdon et al. Resuscitation 2006;71:34-39

  39. In Cardiac Arrest “Your hands are their heart--if you stop chest compressions their “heart” stops and blood flow to their brain stops" Would you want someone certified in CPR to try to resuscitate you when blood flow to your brain would be stopped for 10 to 12 seconds, every 20 seconds?

  40. This recommendation also assumes that trained “Certified” individuals will perform MTM ventilations? • Swor and associates surveyed a large group of bystanders of OHCA and found that only “a minority of CPR-trained and certified” bystanders performed bystander CPR Swor R et al. CPR training and CPR performance: do CPR-trained bystanders perform CPR? Acad Emerg Med 2006;13:596

  41. When asked anonymously, most trained individuals say they would not perform MTM ventilation • Ornato et al “BLS instructors” Ann Emerg Med 1990;19:151 • Brenner et al. “Internists and medical nurses” Arch Intern Med 1993; 153:1763 • Brenner et al. “House-staff” Resuscitation 1994;28:185 • Brenner et al. “House-staff metropolitan vs. rural” Resuscitation 1996;32:5

  42. 2010 AHA Guidelines for CPR and ECC Intubation and hyperventilation common 30:2 No data that “highly trained” will do it; or that it improves survival Circulation 2010;122: October 16th

  43. ECCU 4:45 to 5:35 PM 9/13/12Gordon Ewy MD & Tom Rea, MD • All agree that “Hands only CPR” (CPR without breaths) has been a game-changer. • Is it only for lay providers or is it appropriate for professional rescuers as well? • Is it right for all cardiac arrest victims or just selected patients?

  44. “New CPR”Cardiocerebral ResuscitationPrimary Cardiac Arrest “Guidelines” CPR Cardiopulmonary Resuscitation Secondary Cardiac Arrests

  45. How Do You RecognizePrimary Cardiac Arrest? • Unexpected witnessed (seen or heard) collapse in an individual who is not responsive • Note that this description does not mention pulse (difficult) • Note that this description does not mention breathing (gasping is common) • Gasping is a sign of cardiac arrest

  46. Chest compressions and “rescue breathing” is for respiratory arrest • For respiratory arrest, such as drowning or respiratory arrest secondary to drug overdose or pulmonary failure: Chest compressions plus ventilation • However no evidence that 30:2 is optimal

  47. Chest compressions and “rescue breathing” is for respiratory arrest • “Cafe’ Coronary” Heimlich

  48. ECCU 4:45 to 5:35 PM 9/13/12Gordon Ewy MD & Tom Rea, MD • All agree that “Hands only CPR” (CPR without breaths) has been a game-changer. • Is it only for lay providers or is it appropriate for professionals rescuers as well? • Is it right for all cardiac arrest victims or just selected patients?

  49. Compression Only CPR (CO-CPR) for Non-Cardiac Arrest in ArizonaPotential Harm in Adults with Non-Cardiac Arrest? 20% 15% 10% 5% 0% CO-CPR was only provided in 18% of non primary cardiac arrests P = NS Survival to Hospital Discharge 4.0% 3.8% 2.7% None CPR CO-CPR Panchal, A et al (SHARE) Resuscitation 2012: in press

More Related