REVIEW URRENT C OPINION
High-quality cardiopulmonary resuscitation Jerry P. Nolan
Purpose of review The quality of cardiopulmonary resuscitation (CPR) impacts on outcome after cardiac arrest. This review will explore the factors that contribute to high-quality CPR and the metrics that can be used to monitor performance. Recent findings A recent consensus statement from North America defined five key components of high-quality CPR: minimizing interruptions in chest compressions, providing compressions of adequate rate and depth, avoiding leaning on the chest between compressions, and avoiding excessive ventilation. Studies have shown that real-time feedback devices improve the quality of CPR and, in one before-and-after study, outcome from out-of-hospital cardiac arrest. Summary There is evidence for increasing survival rates following out-of-hospital cardiac arrest and this is associated with increasing rates of bystander CPR. The quality of CPR provided by healthcare professionals can be improved with real-time feedback devices. The components of high-quality CPR and the metrics that can be measured and fed back to healthcare professionals have been defined by expert consensus. In the future, real-time feedback based on the physiological responses to CPR may prove more effective. Keywords bystander CPR, debriefing, feedback devices, high-quality cardiopulmonary resuscitation, mechanical CPR
INTRODUCTION Survival from out-of-hospital cardiac arrest (OHCA) is dependent on optimizing all links in the chain of survival [1]. Early cardiopulmonary resuscitation (CPR) forms the second link in the chain, and it is now well recognized that the quality of the CPR provided impacts significantly on the likelihood of achieving return of spontaneous circulation (ROSC). A recent consensus statement from the American Heart Association (AHA) usefully sets out the factors that contribute to the delivery of high-quality CPR (given below) [2 ]. This review will discuss recent developments in the provision of high-quality CPR. Factors and metrics that contribute to highquality cardiopulmonary resuscitation (adapted from [2 ]): &&
&&
(1) Metrics of CPR performance (a) Minimize interruption – aim for chest compression fraction above 80% (b) Chest compression rate 100–120/min (c) Compression depth at least 5 cm in adults (d) Full chest recoil (e) Avoid excessive ventilation (less than 12 breaths/min and minimal chest rise)
(2) Monitoring and feedback (a) Coronary perfusion pressure above 20 mmHg (if central venous and arterial catheters in situ) (b) Arterial diastolic pressure above 25 mmHg (if arterial catheter in situ) (c) End-tidal carbon dioxide value greater than 20 mmHg (3) Team-level logistics (a) Training nontechnical skills such as team leadership (b) Maximize chest compression fraction by team training and choreography, minimize time to place airway, avoid unnecessary pulse checks, minimize pre-shock pauses (c) Consider mechanical CPR for patient transport
Royal United Hospital, Bath, UK Correspondence to Jerry P. Nolan, Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Combe Park, Bath BA1 3NG, UK. Tel: +44 1225 825056; e-mail: [email protected] Curr Opin Crit Care 2014, 20:227–233 DOI:10.1097/MCC.0000000000000083
1070-5295 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-criticalcare.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cardiopulmonary resuscitation
KEY POINTS There is evidence that survival rates after out-of-hospital cardiac arrest are increasing and the increase in the rate of bystander CPR is a major contributor. The quality of CPR is associated with outcome. A recent consensus statement from North America defines five key components of high-quality CPR. Metrics of CPR performance should be monitored and used during debriefing.
(4) Continuous quality improvement for CPR (a) Debriefing using checklists, data from defibrillator downloads (b) Frequent refresher training (c) Regular system review, for example, cardiac arrest committee meetings
ACTIVATING THE EMERGENCY MEDICAL SERVICES Early recognition of the cardiac arrest and activation of the emergency medical services (EMS) is vitally important because this enables high-quality CPR to be started with minimal delay. A retrospective analysis of the Victorian Ambulance Cardiac Arrest Registry (VACAR) in Australia identified 2842 of 44 499 (6.4%) adult OHCA cases attended by the EMS in which the first bystander call was not directed to the EMS; calls to relatives, friends or neighbours accounted for 60% of these [3]. Survival-to-hospital discharge was significantly improved if bystanders called the EMS first [odds ratio (OR) 1.64, 95% confidence interval (CI) 1.13–2.36]. Public education initiatives, possibly using mass media, should encourage bystanders to first call the EMS in response to medical emergencies.
DISPATCHING AND BYSTANDER CARDIOPULMONARY RESUSCITATION Recent studies have documented increasing survival rates following OHCA [4 ,5,6]. Several factors are likely to have contributed to these outcomes, but an increase in both the rate and quality of bystander CPR and the quality of CPR provided by EMS personnel are likely to be major contributors. Bystander CPR is considered to double survival rates after OHCA; despite this bystander CPR rates remain low in many parts of the world. An analysis of the Danish Cardiac Arrest Registry has documented a doubling in the rate of bystander CPR from 21.1% (95% CI 18.8–23.4%) in 2001 to &&
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44.9% (95% CI 42.6–47.1%) in 2010 (P < 0.001), and this was associated with an increase in 30-day survival from 3.5% (95% CI 2.5–4.5%) to 10.8% (95% CI 9.4–12.2%; P
High-quality cardiopulmonary resuscitation Jerry P. Nolan
Purpose of review The quality of cardiopulmonary resuscitation (CPR) impacts on outcome after cardiac arrest. This review will explore the factors that contribute to high-quality CPR and the metrics that can be used to monitor performance. Recent findings A recent consensus statement from North America defined five key components of high-quality CPR: minimizing interruptions in chest compressions, providing compressions of adequate rate and depth, avoiding leaning on the chest between compressions, and avoiding excessive ventilation. Studies have shown that real-time feedback devices improve the quality of CPR and, in one before-and-after study, outcome from out-of-hospital cardiac arrest. Summary There is evidence for increasing survival rates following out-of-hospital cardiac arrest and this is associated with increasing rates of bystander CPR. The quality of CPR provided by healthcare professionals can be improved with real-time feedback devices. The components of high-quality CPR and the metrics that can be measured and fed back to healthcare professionals have been defined by expert consensus. In the future, real-time feedback based on the physiological responses to CPR may prove more effective. Keywords bystander CPR, debriefing, feedback devices, high-quality cardiopulmonary resuscitation, mechanical CPR
INTRODUCTION Survival from out-of-hospital cardiac arrest (OHCA) is dependent on optimizing all links in the chain of survival [1]. Early cardiopulmonary resuscitation (CPR) forms the second link in the chain, and it is now well recognized that the quality of the CPR provided impacts significantly on the likelihood of achieving return of spontaneous circulation (ROSC). A recent consensus statement from the American Heart Association (AHA) usefully sets out the factors that contribute to the delivery of high-quality CPR (given below) [2 ]. This review will discuss recent developments in the provision of high-quality CPR. Factors and metrics that contribute to highquality cardiopulmonary resuscitation (adapted from [2 ]): &&
&&
(1) Metrics of CPR performance (a) Minimize interruption – aim for chest compression fraction above 80% (b) Chest compression rate 100–120/min (c) Compression depth at least 5 cm in adults (d) Full chest recoil (e) Avoid excessive ventilation (less than 12 breaths/min and minimal chest rise)
(2) Monitoring and feedback (a) Coronary perfusion pressure above 20 mmHg (if central venous and arterial catheters in situ) (b) Arterial diastolic pressure above 25 mmHg (if arterial catheter in situ) (c) End-tidal carbon dioxide value greater than 20 mmHg (3) Team-level logistics (a) Training nontechnical skills such as team leadership (b) Maximize chest compression fraction by team training and choreography, minimize time to place airway, avoid unnecessary pulse checks, minimize pre-shock pauses (c) Consider mechanical CPR for patient transport
Royal United Hospital, Bath, UK Correspondence to Jerry P. Nolan, Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Combe Park, Bath BA1 3NG, UK. Tel: +44 1225 825056; e-mail: [email protected] Curr Opin Crit Care 2014, 20:227–233 DOI:10.1097/MCC.0000000000000083
1070-5295 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-criticalcare.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cardiopulmonary resuscitation
KEY POINTS There is evidence that survival rates after out-of-hospital cardiac arrest are increasing and the increase in the rate of bystander CPR is a major contributor. The quality of CPR is associated with outcome. A recent consensus statement from North America defines five key components of high-quality CPR. Metrics of CPR performance should be monitored and used during debriefing.
(4) Continuous quality improvement for CPR (a) Debriefing using checklists, data from defibrillator downloads (b) Frequent refresher training (c) Regular system review, for example, cardiac arrest committee meetings
ACTIVATING THE EMERGENCY MEDICAL SERVICES Early recognition of the cardiac arrest and activation of the emergency medical services (EMS) is vitally important because this enables high-quality CPR to be started with minimal delay. A retrospective analysis of the Victorian Ambulance Cardiac Arrest Registry (VACAR) in Australia identified 2842 of 44 499 (6.4%) adult OHCA cases attended by the EMS in which the first bystander call was not directed to the EMS; calls to relatives, friends or neighbours accounted for 60% of these [3]. Survival-to-hospital discharge was significantly improved if bystanders called the EMS first [odds ratio (OR) 1.64, 95% confidence interval (CI) 1.13–2.36]. Public education initiatives, possibly using mass media, should encourage bystanders to first call the EMS in response to medical emergencies.
DISPATCHING AND BYSTANDER CARDIOPULMONARY RESUSCITATION Recent studies have documented increasing survival rates following OHCA [4 ,5,6]. Several factors are likely to have contributed to these outcomes, but an increase in both the rate and quality of bystander CPR and the quality of CPR provided by EMS personnel are likely to be major contributors. Bystander CPR is considered to double survival rates after OHCA; despite this bystander CPR rates remain low in many parts of the world. An analysis of the Danish Cardiac Arrest Registry has documented a doubling in the rate of bystander CPR from 21.1% (95% CI 18.8–23.4%) in 2001 to &&
228
www.co-criticalcare.com
44.9% (95% CI 42.6–47.1%) in 2010 (P < 0.001), and this was associated with an increase in 30-day survival from 3.5% (95% CI 2.5–4.5%) to 10.8% (95% CI 9.4–12.2%; P
