QUALITY OF CPR

Dr Sreekrishnan T P
AIMS,Kochi
 Objectives
• Overview of BLS and high quality CPR

• Components of high quality CPR

• Each in detail with 2015 recommendation

• Compression fraction

• Ancillary CPR devices

• Quality assessment
 ADULT BLS AND CPR QUALITY OVERVIEW

• Sudden cardiac arrest remains a leading cause of

death

• 70% of out-of-hospital cardiac arrests occur in the

home , approximately 50% are un witnessed

• 10.8% survival to discharge

 Survival to discharge
30

25

20

15
Survival to discharge

10

0
OHCA IHCA
• In-hospital cardiac arrest-22.3% to 25.5% survival
• Chain of survival
 High Quality CPR

• Ensuring chest compression of adequate rate

• Ensuring chest compressions of adequate depth

• Allowing full chest recoil between compressions

• Minimizing interruptions in chest compressions

• Avoiding excessive ventilation

 Technique
• Chest compression- key component of effective CPR

• Characteristics include depth, rate and degree of recoil

• Quality of CPR is also influenced by

• - rate and depth of compression

• - allowing adequate time for recoil
• - minimizing interruption
• - avoiding excessive ventilation
 Hand Position
• 2015 recommendation- unchanged

• Class IIa LOE C-LD

• Consistent with 2010 guidelines

• Reasonable to position hands on the lower half of the

sternum

• Investigations, positioning over the lower v/s centre

• No conclusive or consistent results on resuscitation outcomes

 Chest compression rates
• In 2010 guidelines-at least 100 /minute

• 2015 – optimal zone is between 100 -120/min showed improved

survival

• Class II a LOE C-LD

• Interdependent relation between compression rate and

compression depth

• If rate > 120/min depth decreases

• COMPRESSION AT THE RATE OF 100-120/MIN

Chest compression depth
• 2010 - recommends compression depth at least 2
inches

• 2015 : reviewed whether chest compression

depth different from 2 inches has any influence of
physiological or clinical outcome

• Depth – increases intrathoracic pressure -

influence forward blood flow from the heart
 Evidence
• Evidence involving compression depth derived from
observational human studies

• Evaluated relationship between depth and outcomes

-survival with favorable neurological outcome
- survival to hospital discharge
- ROSC
• Optimal compression depth with regard to survival
occurred within the ranges of 4.1-5.5 cm or 1.61-2.2
inches

• CPR injuries are more common when compression

depth is more than 6 cm and is less between 5 and 6
cm

• 2015 – DURING MANUAL CPR RESCUERS SHOULD

PERFORM COMPRESSIONS ATLEAST AT A DEPTH OF 2
INCHES OR 5 CM,WHILE AVOIDING EXCESSIVE CHEST
COMPRESSION DEPTH(>2.4INCHES OR 6 CM)

• Class I ,LOE C-LD

 CHEST WALL RECOIL
• 2015: Reviewed whether full chest wall recoil versus
incomplete had any physiologic or clinical outcomes

• Full chest wall recoil- sternum returns to its natural or

neutral position

• It creates a relative negative intrathoracic pressure that

promotes venous returns and cardio pulmonary blood
flow
• Leaning on the chest wall between compressions
doesn’t allow full chest wall recoil

• Incomplete recoil could increase the intrathoracic

pressure and reduce the venous return , coronary
perfusion and myocardial blood flow

• Evidence- no human studies

• Increased force of leaning was associated with

decrease in coronary perfusion
• Increased force of leaning was associated with
decrease in coronary perfusion

• 2015 : IT IS REASONABLE FOR RESCUERS TO

AVOID LEANING ON THE CHEST BETWEEN
COMPRESSIONS TO ALLOW FULL CHEST WALL
RECOIL

• Class II a LOE C-LD

 MINIMIZING INTERRUPTIONS
• Major point of emphasis

• 2015 : reviewed whether shorter compared

with longer interruptions had any influence in
physiological or clinical outcomes

• Interruptions can be as a part of required care

or not
 Chest compression fraction
• Measurement of proportion of time that compressions
are performed during a cardiac arrest

• Increasing this can be achieved by minimizing pauses

• Optimal goal for CCF has not been defined

• AHA experts consences is that a CCF of 80% is

achievable at a variety of settings
 Evidence
• Observational and randomized human study of cardiac arrest

• Heterogeneous results

• Observational studies demonstrates association between

• Shorter duration of compression interruption for the peri shock

period and a greater likelihood of shock success ROSC and survival

• Higher CCF and likelihood of survival among patient with shockable

rhythms and ROSC among patients with non shockable rhythms
• CCF determines survival in patients with out of
hospital VF(Circulation 2009;120:1241-1247)

• Total 506 case analysed

• An increased CCF is independently predictive

of better survival in patients who experience a
prehospital VF/VT arrest
 CCF Survival

30
25
20
0-20% n=100
Percentage 15
Surviving 21-40% n= 74
10 41-60% n= 117
5 61-80% n= 143
0 81-100% n= 72
 2015 recommendation
• Total pre shock and post shock pauses in chest
compression should be as short as possible
• Class I LOE C-LD

• Without an advanced airway it is reasonable to pause

compression for less than 10 seconds to deliver two
breaths
• Class II a LOE C-LD

• With an unprotected airway it may be reasonable to

perform CPR with a goal of CCF as high as possible with
a target of at least 60%
• Class II b LOE C-LD
 Ventilation
• 30:2
• Class II a LOE C-LD

• With advanced airway

• One breath every 6 seconds

• Compression at a rate of 100 to 120 /min

 Chest compression feedback
• It may be reasonable to use audiovisual
feedback devices during CPR for real time
optimization of CPR performance

• Decreases the leaning force during chest

compression

• No proven neurological outcome or survival

 Delayed ventilation
• For witnessed OHCA with a shockable rhythm

• Reasonable for EMS system with priority based multi

tired response to delay PPV

• By using a strategy of up to 3 cycles of 200 continues

compressions with passive oxygen insufflations and
airway adjuncts followed by shock

• Showed improved survival

 Team resuscitation
• For HCPS

• 2015 guidelines allows flexibility for activation

of emergency response

• Subsequent management in order to better

match the providers clinical setting
 Alternative techniques and ancillary
devices

• Impedance threshold devices

• Mechanical chest compression devices
• Load distribution band devices
• Extra corporeal techniques
• Invasive perfusion devices
 Impedance threshold devices
• 2010 – may be considered by a trained personnel as a CPR
adjunct

• 2015- routine use of ITD as an adjunct during conventional

CPR is not recommended
• Class III LOE A

• Combination of ITD with active compression

decompression CPR maybe reasonable alternative to
conventional CPR with available equipment and
experienced personnel
• Class II b LOE C -LD
Mechanical chest compression devices
• 2010- maybe considered for use by properly trained
personnel in circumstances like diagnostic and
interventional procedures

• 2015- evidence does not demonstrate a benefit

• May be reasonable alternative for use by properly trained

personnel
• Class II b LOE B-R

• Manual chest compression reminds the standard of care

• May be a reasonable to conventional CPR
• Where the delivery of high quality of manual
compression will be challenging or dangerous
for the provider
Class II b LOE C-EA
• Like limited rescuers availability
• Prolonged CPR
• CPR during hypothermic cardiac arrest
• CPR in moving ambulance/angiographic suite
• ECPR
 Load distribution band devices
• Circumfrential chest compression device

• Composed of a pneumatically actuated constricting band and

backboard

• The evidence does not demonstrate a benefit with the use of LDB-
CPR versus manual

• Reasonable alternative when trained personnel is available(Class II

b LOE B-R)

• In specific situation may be use full when manual CPR is

difficult(Class II b LOE –EO)
 Extra corporeal techniques and
invasive perfusion devices
• 2010- insufficient evidence to use

• 2015- ECPR maybe considered for selected patients who have

cardiac arrest and whom the suspected etiology of cardiac arrest is
potentially reversible

• Class II b LOE C-LD

• Complex process, highly trained team specialized equipments

required

• Arrest of cardiac origin after conventional CPR for more than 10

mins without ROSC
 Team based resuscitation
• Resuscitation involves a team of care givers

• Designated team leader is needed

• He aims to minimize
• - interruptions in CPR
• - ensure delivery of adequate compression rate and depth
• - minimization of leaning
• - avoidance of excessive ventilation
Components of high quality CPR
Scene safety
Recognition of cardiac arrest
Activation of EMS
Compression- ventilation ratio
without advanced airway
Compression- ventilation ratio
with advanced airway
Make sure that environment is safe for rescuers and
victim
Check for responsiveness
No breathing or no normal breathing
No definite pulse within 10 seconds
(Breathing and pulse check can be done
simultaneously)
Alone with no mobile: Activate EMS and get AED
before CPR
Other wise :Send someone and start CPR
Use AED as soon as its available
1 or 2 rescuers 30:2
Continuous compressions at a rate of 100-120/mt
Give 1 breath every 6 seconds
Compression rate 100-120/mt

Compression depth At least 2 inches(5 cm)

Hand placement 2 hands on the lower half of the

sternum

Chest recoil Allow full recoil of chest after each

compression , do not lean in
between compression

Minimizing interruptions Limit interruptions in chest

compressions less than 10 seconds
Do’s Don'ts
Perform chest compression at Compression rate slower than
a rate of 100-120/min 100 or greater than 120/mt
Compress to a depth of at Compress to a depth of less
least 5 cm (2 inches) than 5 cm or greater than 6
cm(2.4 inch)
Allow full recoil after each Lean on the chest between
compression compressions
Minimize pauses in Interrupt chest compression
compression greater than 10 s
Ventilate adequately (30:2 Provide excessive ventilation
,deliver breath over 1 s ,each
causing chest rise)
THANK YOU