CPRProblemsandSolu1ons

FernandoJPerez,MDRobertTrenkamp,ParamedicJuly9,2016

TheShortForm

•  SLICCexaminedandanalyzeddata:– On50Bystanders(2013)whoseagedistribuConapproximatedthatofcardiacarrestvicCms1

– On44EMSworkers(2014,5)fromoneofsevenEMS’stested.TheothersixEMSdatasetsappearsimilar.

•  SLICCidenCfiedsoluConsforeachoftheproblemsevidentinthedata.

•  NB:SomeofthismaterialwaspublishedinGemCIinAprilof20161.SomewaspresentedatECCUinDecemberof2015

WhereCardiacArrestsHappen…•  Eightypercentofarrestshappeninaprivateresidence.(Seventypercentathome2.)– ~247,200malesperdayarrest3

– ~152,800femalesperdayarrest3

– 48.4percentofthe70%arewitnessed3,•  Thespouseisthemostlikelywitness.•  TheotherpersoninaprivateresidencedoesnotalwaysknowattheCmeofthearrestthatthevicCmarrested.

HowManyArrestVic1msSurvive?

•  TherearetwoaccounCngsystems:– Summary:#survivorsdividedbythe#ofvicCms– Utstein:#survivorsdividedbythe#vicCmspresenCngtoEMSinshockablerhythm.

•  KingCounty(WA),Phoenix(AZ),&Anchorage(AK)report35%to65%survival(Utstein)

•  NaConally,28%ofthoseresuscitatedfromashockablerhythmsurvive4.

WhyLargeDifferenceBetweenaTenPercentNa1onalAverageandThis?

•  ThevicCmswhopresentwithashockablerhythmhaveafargreatersurvivalrate(28%)thanthosethatdonot(4%).

•  TheorganizaConsthatusetheUtsteincriteriahavealsoworkedtoimproveallaspectsoftheresuscitaConprocess.ThisincludesKingCounty,Phoenix,HiltonHeadIsland,andothers.

WhatIsASurvivor?

•  AvicCmbecomesa“survivor”upondischargefromthehospital,capableofhandlingtheAcCviCesofDailyLivingwithoutassistance.

TwoMajorRootCausesOfResuscita1onProblems

•  LackofResuscitaConQualityControl•  UnderweightRescuersPerformingChestCompression

Forceavailableisdeterminedbyyour“handsonScaleweight”anddecelera1onforcesinthevic1m’schestwhenperformingManualCompression.GreaterrescuerweightcanbeappliedwhenperformingHeelCompression5.

Implica1onsOfPreviousSlide•  Theaverageadultchestrequires130poundstocompresstoatwo-inchdepth.– Mychestrequiresabout145poundsofforcetocompresstoatwo-inchdepth;

– Mywifeweighs114pounds;–  Thus,wehaveanAEDathomewithineasyreach;– …andwetakeitwithuswhenwetravel.

•  EightypercentofAdultchestscanbecompressedtodepthwith178poundsofforce5.

•  TogetaCPRcardyouaretestedonamanikinthatlikelyissomewherebetweenthe20thand50thpercenCleofadultchestsCffness.

CompressionDepth

•  ThepercentageoftheadultpopulaConarescuercancompresstotwoinchdepthdependsupon:– RescuerWeight– RescuerWeightDistribuCon– VicCmChestSCffness– Compressionmethod6used.

•  Manual(withtwohands)•  Heel(withtheheelofafoot)

Foreachgroup,theupper-le]pointiswhateverybodyinthegroupcando.Thelower-rightpointisthebestanybodyinthatgroupcando6.

WhereDoesThisLeaveUs?•  InacohortwhoseagedistribuConapproximatedthatofarrestvicCms

onlyallmalesusingheelcoulddobelerthan60%ofadults:

•  Thisshormallisafundamentalbarrierbecauseit’sdeterminedbyweightandweightdistribuCon:Trainingandsupervisioncannotimproveit.

•  Weightedvestsweretestedwithmixedresults.

FemaleManual

MaleManual

FemaleHeel

MaleHeel

Whateveryone

inthegroupcan

do

5% 20% 30% 60%

WhatbestIndividualingroupcando

40%

80%

70%

95%

OtherCPRProblems…

ProblemAreas Bystanders(150) EMSPersonnel(383)

ManualChestCompression DuraCon(stamina)Rate(someCmesslow)Leaning(unknown)

DuraCon(stamina)Rate(usuallytoofast)Leaning(Frequent,Severe)

VenClaCon n/a HypervenClaCon7Common

EMSSolu1onsProblemArea EMSPersonnel HowtoMakeItHappenCompressionDepth MechanicalChest

Compression,or216#minimumcrewweight.

Requiresrequirementfromeachstate’sEMSDirector

DuraCon MechanicalChestCompression,or216#minimumcrewweightandextracrew.

MulCplepeoplehelp,buttwoisnotenough.

Rate QAOfficeratallcodes. Wheretheydothis,ithelps.

Leaning ClickerorElectronicDevice Canpurchaseelectronicdeviceoruseclicker.

VenClaCon Emory’svalveonlyaddsO2toBVMwhenit’sCmetovenClate.

NeedtofindavendortocommercializetheEmoryClicker.

EmployeeevaluaConandtraining.

TheCPRForceMetermonitors,displays,andrecordsrate,force,andleaningevery8-16milliseconds

EMS’sneedtoknowwhichoftheiremployeesneedstraining.CounCngcompressionsfortwominutesanddividingby2doesn’twork.

BystanderSolu1onsProblemArea Bystanders HowtoMakeItHappenCompressionDepth HeelCompression,FamilyAED Free,onlineHeelTraining;

Lease-to-OwnAEDprogram(amindiscussionnow)

DuraCon HeelCompression,FamilyAED Heelcompressionquadruplesthenumberofpeoplewhocancompressfortenminutes.

Rate HumSong(training) Includeintraining

Leaning Clicker Needtofindsomeonetomanufacturetheclicker

Un-witnessedArrest iPhoneappthatreportsarrests&locaContoEMS

“comingsoon”

TheClickerGoesonChest.Clicksondownstroke,Clicksagainwhenforceonitdropsbelow1.8#7.Es1matedsalesprice$10-$20.Laerdalhas$895unitthatcoachesrate,depth,leaning.

Why This Matters

• Someone in the Untied States dies of a cardiac arrest every 88 seconds.

• Few resuscitation attempts produce Guideline-Compliant Chest Compression (“GC3’s”) throughtout.

• We are in the midst of a transition from totally un-measured CPR to totally measured CPR. The AHA has called for the instrumenting the CPR process, and Zoll’s “dashboard” is a good start.

• The data reflecting these measurements will work its way into the records:

o Compression depth;o Compression rate, including

instantaneous, maximum, minimum, and average;

o Ventilation rate;o Number, timing, and duration of

interruptions;o Leaning.

• It is important for purely medical reasons and for legal risk avoidance that we adopt the tools that permit an organization to monitor and train their personnel in the elements of CPR and either:

o always schedule the staff in a manner that results in somebody’s being able to perform GC3’s on at least 90% of the adult population, or

o (b) provide mechanical compression devices for the staff to use.

Saving Lives In Chatham County, Inc. 17 Hasleiters Retreat Savannah, GA 31411 912-667-1755 www.slicc.org

CPR High Speed, Precision

Force Meter CPR Training, Testing, Quality Control You cannot control a process unless you can measure it. That is a fundamental tenet of Quality Control. The depth of the compression depends upon the weight and weight distribution of the person performing compressions and the stiffness of the victim’s chest. The graph below shows the force required under the 2005 (red), 2010 / 2015 (blue) guidelines. One-inch (prior to 2005) implications are shown in green. And “a” is the chest stiffness index, calibrated on the right scale.

If you do not know the force on the chest at the top and bottom of each compression and the instantaneous compression rate, you don’t know whether he or she can deliver GC3’s at all or to what portion of the adult population, if they can. The CPR Force Meter permits you measure leaning, compression rate, and rate uniformity. Exact instantaneous rate measurements are made by pasting the tabular data into a copy of the Excel template provided with the CPR Force Meter.

ForceMeterShowsRealRate

RowLoca1onsHOSW Trial#1 Trial#2

Begin 1313 2259 4565End 1324 3179 5076

Avg%ofHOSW 134% 135% AvgRate Trial#1 Trial#2

MaxForce 138 206 204PoundsCompressions 77 77

AvgForce 136 182 184Pounds Seconds 27.998 26.381MinForce 134 132 0Pounds 36.736 14.217

Compr/min 142 134MaxRate 360 195Comps/MinuteAvgRate 256 111Comps/MinuteMinRate 72 76Comps/Minute

MaxLean 39.7 22.7PoundsAvgLean 5.0 5.5PoundsMinLean 0.0 0.0Pounds

Thissubjectwascoachedaboutrateandleaningbetween1stand2ndtrial.Subjectbroughtaverageratedown,butmuchofthe77secondtrialwasataratewellabove120/min,andleaninggotworse.Averagesdon’ttellatruestory.

ForceMeterShowsLeaning

AnnouncingUn-witnessedArrests•  Smartphoneapp+smartwatch;•  Preferencesinclude

–  Homeaddress(es),GPScoordinatesforeach.•  Whenathome,addressistransmiled,otherwiseGPS;

– WhomtonoCfy+contactinformaCon.–  Custommessage(s)

•  Evena50%falseposiCverateburdensdispatchandEMSlessthan2.5%

•  FalsenegaCveratemustbeextremelylow.•  SLICCdonatedproductconcepttoalargecompanycapableofcompleCngthedevelopment.

Cita1ons1.  SLICC Presentation #30 at AHA ReSS 2013. 2.  Robert Trenkamp, EMT-P, F.J.Perez, MD The prevalence and magnitude of common CPR problems, their probable

root causes, and strategies for the reduction or elimination of these problems. General Internal Medicine and Clinical Innovation, April 2016. doi: 10.15761//GIMCI.1000117

3.  AHA Statistical Update. HeartDiseaseandStrokeSta1s1cs—2015Update(Circula(on2015;131:e29-e322DOI:101161/CIR0000000000000152)Page 207

4.  CARES Registry for 2015 through 12-31-2015 5.  Mohamud R. Daya, Robert H Schmicker, et al, , Current burden of Cardiac Arrest in the United States: Report from

the Resuscitation Outcomes Consortium for 2013 6.  Robert Trenkamp,, EMT-P, FJ Perez, MD Heal compressions quadruple the number of people who can perform

chest compression for ten minutes. American Journal of Emergency Medicine 33 (2015) 1449-1453 http://dx.doi.org/10.1016/j.ajem.2015.06.070

7.  Calculated from the Philips Chest Stiffness Data 8.  From data collected and reported. See http://www.slicc.org/ReSS_2013_030.pdf 9.  Aufderheide, TP, Lurie, KG Death by hyperventilation: a common and life-threatening problem during

cardiopulmonary resuscitation. 10. Buleon Clement, Delaunay Julie, Parienti Jean-Jacques, Hal- bout Laurent, Arrot Xavier, Gerard Jean-Louis,

Hanouz Jean-Luc, Impact of a feedback device on chest compression quality during extended manikin cardiopulmonary resuscitation, American Journal of Emergency Medicine (2016), doi: 10.1016/j.ajem.2016.05.077

LinkstoRelatedInforma1onPresentaCon:AHAReSS2012:HeelCompressionsvsManualCompressionsPresentaCon:AHAReSS2013:PercentofAdultpopulaConcompressiblewithHeelCompressionsvsManualCompressionsPresentaCon:AHAReSS2014:PrevalenceandmagnitudeofleaningintheBystanderpopulaConPresentaCon:ECCU2015:FixingCPR:What’swrongwithCPRandwhatcanwedoaboutit?

LinkstoRelatedInforma1onAbstract:HeelCompressionQuadruplestheNumberofPeopleWhoCanPerformChestCompressionsforTenMinutes.AmericanJournalofEmergencyMedicine,October2015PublicaCon:TheprevalenceandmagnitudeodcommonCPRproblems,theirprobablerootcauses,andstrategiesfordeducConoreliminaConofthoseproblems.PublishedinGeneralInternalMedicineandClinicalinnovaCon,April22,2016Volume1(3):57-60doi:10.15761/GIMCI.1000117