Not Your Grandma s CPR

Transcription

1 Not Your Grandma s CPR T H E F U T U R E O F C A R D I O P U L M O N A R Y R E S U S C I T A T I O N K E V I N B U R G E S S, N R P, C C F P Z O L L C L I N I C A L E D U C A T O R 1

2 Objectives Explain Intrathoracic Pressure Regulation Therapy and it s importance in perfusion Discuss how the current way we do CPR is flawed Explore better ways of doing CPR: IPR Therapy CPR with the ResQPOD Pit Crew CPR Explain how hyperventilation and hypoventilation effect CPR survival rates Discuss the new science of CPR 2

3 Sudden Cardiac Arrest Incidence 2013 OHCA: 359, IHCA: 209, Survival to Discharge Rates In-hospital: 23.9% Out-of-hospital: 11% Source: Resuscitation Outcomes Consortium Cardiac Epistry and Get With The Guidelines -Resuscitation data 3

4 2013: OHCA Survival 11% Survival to Hospital Discharge Source: Resuscitation Outcomes Consortium Cardiac Epistry and Get With The Guidelines - Resuscitation data 4

5 CPR Limitations 5

6 Intrathoracic Pressure Regulation (IPR) 6

7 Intrathoracic Pressure The body continually regulates the circulation of blood by using positive and negative pressures inside the thoracic cavity. 3 Critical Body Systems: Respiratory, Circulatory and CNS 7

8 Normal Physiology When you exhale (exhalation), you increase positive pressure, which Forces air out Inhibits blood return to the heart Increases ICP Conversely when you inhale (inspiration), you increase negative pressure, which Pulls air into lungs Returns blood to the chest Lowers ICP Body at Rest 8

9 Intrathoracic Pressure 9

10 Effect of Intrathoracic Pressure on Blood Flow Respiration and circulation are closely linked. Dating back to 1967, we have known there is an inverse relationship between intrathoracic pressure and blood flow. Intrathoracic Pressure (cmh 2 O) intrathoracic pressure decreases... blood flow increases Blood Flow, Abdominal Vena Cava (l/min -1 ) Moreno et al. Respiratory regulation of splanchnic and systemic venous return. Am J Physiol 213: ,

11 Impedance Threshold Device (ITD) 11

12 ResQPOD Impedance Threshold Device (ITD) The ResQPOD selectively prevents air from reentering the lungs during chest wall recoil. This enhances the vacuum needed to pull blood back into the heart and lower ICP. As a result, more blood is circulated to the brain and vital organs. 12

13 ResQPOD Animation 13

14 ICP Aortic Pressure Effect of IPR on: Aortic and IC Pressures ITD 30 sec. 14 ST (9/23/09)

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16 Key Points to Remember The body regulates positive and negative intrathoracic pressure to regulate blood flow While CPAP regulates positive pressure to impact blood flow, IPR regulates negative pressure to impact blood flow IPR enhances negative pressure to increase preload, lower intracranial pressure and improve circulation to the brain and vital organs. IPR is currently delivered non-invasively through impedance threshold devices, or ITDs. 17

17 Optimizing Outcomes Following Cardiac Arrest 18

18 Sudden Cardiac Arrest Sudden cardiac arrest (SCA) Heart suddenly stops Brain damage and death 11% OHCA Survival 19

19 Why only 11%? 20

20 Dr. Lance Becker "We lose more than 1000 lives each day in the United States from sudden, unexpected death, a fatality rate comparable to the crash of two 747 aircraft without survivors. 1 Lance B. Becker, MD, is a Professor of Emergency Medicine at the University of Pennsylvania and the Director of their Center for Resuscitation Science 21

21 Circulatory Support We need to increase the flow! 22 22

22 Cardiopulmonary Resuscitation Provides 20-30% of normal cardiac output 23

23 Why is Blood Flow Limited During CPR? Chest wall relaxation creates negative pressure (i.e. vacuum) As the chest wall relaxes air rushes into chest through an open airway Diminishing the negative pressure = decreased preload and cardiac output 24

24 Why is Blood Flow Limited During CPR? INCOMPLETE RECOIL Rescuer Fatigue Stiff/Non-Compliant Chest Broken Ribs Compression Rate 25

25 Why is Blood Flow Limited During CPR? Hyperventilation: Diminishing the negative pressure = Decreased preload and cardiac output Increased gastric inflation Respiratory Alkalosis = Shifts the dissociation curve to the left, reducing o2 delivery to tissue. Cerebral Vasoconstriction 26

26 Porcine Survival Study Death by Hyperventilation Group 1 Seven pigs V-fib for 6 min Comp: 100/min Vent: 30/min CPR for 6 min Shock(s) as necessary Survival: 1/7 (14%) Group 2 Seven pigs V-fib for 6 min Comp: 100/min Vent: 12/min CPR for 6 min Shock(s) as necessary Survival: 6/7 (86%*) *P=.006 Aufderheide et al. Circulation 2004;109:

27 High Perfusion CPR The focus of CPR should be to achieve high levels of perfusion to the brain and vital organs during cardiac arrest and higher neurologically intact survival rates High Perfusion CPR involves tools and techniques that achieve high quality CPR with high levels of perfusion to the brain and vital organs 28

28 CPR Circulates Blood by alternating positive and negative pressures inside the chest (Intrathoracic Pressure During CPR) 29

29 Negative Pressure Very important, to increase the flow! Enhanced negative pressure = more vacuum More Preload Increased Cardiac Output Decrease ICP Save the Brain! 30

30 Airway Pressures During CPR Conventional CPR CPR with ResQPOD Vacuum is Limited as air is drawn in (minimal PRELOAD) 31

31 BP and ICP During CPR Conventional CPR CPR with ITD Pirrallo et al. Resuscitation

32 Pre-Clinical Evidence Supports Use of the ITD Pre-clinical * research has demonstrated that during CPR the ITD: Doubles blood flow to the heart 2,6 Doubles SBP (ETCO2) Increases blood flow to the brain by 50% 3,4,5 Lowers ICP 3,4,5 *Pre-clinical data may not indicate clinical results. 33

33 Survival to Hospital Discharge (%) Improved Long-Term Survival S-CPR (n=1641) S-CPR & ITD (n=1605) All Patients V-Fib/V-Tach Good Discharge 30% improvement (p=0.007) 61% improvement (p<0.001) 79% improvement (p=0.038) Aufderheide et al (3,000 cardiac arrest patients) 34

34 ROC PRIMED Study - Neutral? Results: Of 8718 patients included in the analysis, 4345 were randomly assigned to treatment with a sham ITD and 4373 to treatment with an active device. A total of 260 patients (6.0%) in the sham-itd group and 254 patients (5.8%) in the active-itd group met the primary outcome (P=0.71). Conclusions: Use of the ITD did not significantly improve survival with satisfactory function among patients with out-of-hospital cardiac arrest receiving standard CPR. N Engl J Med 2011;365:

35 Improper Chest Compression Rates Decrease Survival Optimal Range for Survival Study found: Many health care providers do not perform CPR at recommended rate. Survival is directly related to chest compression rate. Survival was best when compression rates were between /min (110) Idris et al. Circulation 2011;124:A

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37 Ventilation and Compression Strategies 38

38 Ventilations 39

39 Effect of Positive Pressure Ventilation 1. Delivers air/o 2 to lungs and re-inflates lungs, enabling gas exchange 2. Facilitates CO 2 clearance 3. Lowers resistance to trans-pulmonary blood circulation (improves R to L flow) 4. Increases ICP, lowering brain blood flow 5. Reduces venous blood return 6. Lowers cardiac output 7. Pushes blood out of lungs to left heart 8. Reduces interstitial fluid in lungs 40

40 Apneic Oxygenation 41

41 Lots of Ventilation Options None 50:2 30:2 15:2 5:1 42

42 Effect of Pausing for Ventilation During Compressions Turner et al - Resuscitation

43 Are No Ventilations Better? Methods: 16 pigs with induced V-fib; 8 min. downtime; then CPR for 8 min with chest 100/min N = 9 pigs (NV) CPR - no ventilations N = 7 pigs (PPV) CPR w/ ventilations 44% v/s 71% Primary endpoint: Survival to 24 hours neurologically intact (CPC of 1 or 2) Yannopoulos et al - Crit Care Med 2009 Cerebral Performance Categories 44

44 Effect of Gasping During Cardiac Arrest Airway Ao RA ICP ECG 45

45 Compressions 46

46 Chest Compressions: Importance of Complete Recoil Ventilation Compressions / Decompressions 47

47 Stay On the Chest! Interventions: 1. Delayed intubation compressions before first shock 3. Minimize pre and post shock pauses 4. Primary focus on compressions, secondary focus ventilation Tripled survival to hospital discharge (3.8% 9.1%) Bobrow et al JAMA

48 OK City-Tulsa Metro Experience Metronome discontinued and patient turned over to hospital personnel at 39:00. 49

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52 Heads Up CPR Gathering of Eagles - Debaty; Shin; Metzger; Lurie 53

53 Heads Up CPR Gathering of Eagles - Debaty; Shin; Metzger; Lurie 54

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56 ResQPUMP 57

57 ResQCPR was born in 1987 CPR: The P Stands for Plumber s Helper. Lurie et al - JAMA

58 ACD-CPR Active Compression Decompression CPR Metronome Force Gauge Handle Suction Cup 59

59 ResQCPR Animation 60

60 ResQTRIAL Standard CPR (S-CPR) ACD CPR + ITD (ACD+ITD) 61

61 BP and ICP During CPR Conventional CPR CPR with ITD ACD-CPR with ITD Pirrallo et. Resuscitation

62 Percent (%) Survival at One Year 49% Improvement S-CPR ResQCPR n=794 n=822 Cardiac Etiologies Source: ResQCPR System Summary of Safety and Effectiveness Data submitted to FDA 63

63 ml/min/gm Near-Normal Blood Flow to the Brain * 60 *67% Improvement P=0.028 Pre-Arrest S-CPR 20 ResQCPR 10 0 Voelkel et al. Pediatr Res 2002;51: Pre-clinical data may not be indicative of clinical outcomes. 64

64 Saving the Brain 65

65 Questions? 66

66 Question? List 3 reasons Why is Blood Flow Limited During CPR? 67

67 Kevin Burgess 68