What is the ideal chest compression:ventilation ratio?

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What is the ideal chest compressionventilation
ratio?

• Ventilation Perfusion Match
• Good CPR 1/4 - 1/3 of normal cardiac output
• alveolar ventilation 1/4 - 1/3 of normal
• Additional breaths
• dead space ventilation
• Increase IT pressure

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CPR ratios
Mathematical model Lay rescuers - adult victims
502 best
Babbs, Resuscitation 200461
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• Guidelines 2005- Ventilation
• Compression/Ventilation Ration 302
• Deliver each rescue breath over 1 second
• Give enough volume to produce visible
  chest rise
• Avoid rapid and forceful breaths
• Advanced Airway- give 1 breath every 6-8
  seconds

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4

• Emphasis ?
• effective chest compression defibrillation

• Chest Compressions Only ?Continuous chest
  compression (CCPR)
• Shock First or CPR First

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Survival From Simulated CPR
80
73
70
24 hr CNS NORM
40
7
0
CC Only IDEAL CPR NO CPR
Ewy et al Circulation 20051112134-42
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Probability of Survival to Hospital Discharge
Wik, L. et al. JAMA 20032891389-1395.
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Defibrillation or CPR First
survival
Wik, JAMA 2004
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Phases of VF Cardiac Arrest
JAMA 20022883035
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Phases of VF Cardiac Arrest
JAMA 20022883035
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• Guidelines 2005-
• CPR before Defibrillation
• Immediate defibrillation is the treatment of
  choice for VF of short duration
• OOH unwitnessed (EMS) VF, may give period
  CPR before rhythm check

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• Emphasis ?
• effective chest compression defibrillation

• Single or Stacked Shocks
• Pulse Check
• Rhythm Check

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Major Recommendations

• Single shock
• Followed by immediate CPR

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1st Shock delivered
22 seconds after pads placed
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RE-VF 25 seconds after the 1st shock
(No Chest Compressions yet)
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2nd Shock delivered 34 sec after re-VF
(Still No Chest Compressions)
CPR finally begun after 1 min 17 sec from 1st
shock
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Monophasic vs Biphasic WaveformShock Efficacy VF
N Waveform Energy 1st 2nd 3rd
54 BTE 150, 150,150 96 96 98
48 MTE 200, 200, 360 54 60 67
13 MDS 200, 200, 360 77 77 77
No waveform consistently related to ? ROSC or
Hospital Discharge
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Defibrillation Success Out-of-Hospital Cardiac
Arrest

• First Shock Results (N21/61)
• Remained in VF- 19
• Shocked into Non-VF 81
• Perfusing rhythm ? 0

_at_TIME RESUME CPR 45 SECONDS
Kern Circulation 2002
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Prompt CPR after AED
p lt0.05
10/18
9/18
9/18
Percent
3/18
3/18
3/18
Kern
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Will CPR Do Harm Post-Shock

• Most post-shock PEA is pseudo-PEA -some
  pressure generated (10/5 or 20/10 mmHg)
  -undetectable as a palpable pulse
  (Aufderheide/Monday)
• Chest Compressions during post-shock organized
  rhythms does not precipitate re-VF
  (Hess White)

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• Guidelines 2005-
• CPR after Defibrillation
• Resume CPR immediately following shock
  (and while charging)
• No pulse or rhythm check for 5 cycles CPR (_at_
  2 minutes)

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ACLSMajor Recommendations

• ? Emphasis advanced airway
• Recommendation Intraosseous access
• ? Emphasis ET drug administration

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ACLS PRIORITIES2 MINUTE CYCLES- TEAM DYNAMICS
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ECC New Course Emphasis

• Team Dynamics and Leadership
• Outcome is determined by success of team and not
  the individual

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ACLSMajor Recommendations

• Amiodarone Lidocaine
  either
• Epinephrine- Vasopressin
• ET discouraged
• Atropine 0.5 mg - ACS

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Summary ACLS

• Emphasis on High-Quality CPR
• Simplified Algorithms
• Recommend expert consultation
• Use IV / IO Access
• limit ET administration
• Limit, defer Advanced Airway Use
• Especially endotracheal tube
• Primary confirmation of ET- dual method

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Key studies- Amiodarone
ARREST TRIAL Kudenchuck 1999
Patient group n Survival to admission Odds ratio for admission Survival to discharge
Amiodarone 246 44 1.6 13.4
Placebo 258 34 (p 0.03) (p 0.02) 13.2 (p ns.)
ALIVE TRIAL Dorian 2002
amiodarone 5 mg/kg vs. lidocaine 1.5 mg/kg)
Patient group n Survival to admission Survival to discharge
Amiodarone 180 22.8 5
Lidocaine 167 12.0 (p 0.009) 3 (p 0.34)
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Vasopressin-Epinephrine
Group n ROSC Survival admission Survival 24 h Survival discharge
Vasopressin 20 80 70 60 40
Epinephrine 20 55 (p 0.18) 35 (p 0.06) 20 (p 0.02) 15 (p 0.16)
Lindner 1997
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Vasopressin-Epinephrine
Patient group (all rhythms) n Survival to 1 hour Survival to discharge
Vasopressin 104 39 12
Epinephrine 96 35 (p 0.66) 14 (p 0.67)
PEA n 95 Survival to 1 hour Survival discharge
Vasopressin 33 9
Epinephrine 29 10
Stiell 2001
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Vasopressin-Epinephrine
VF/VT (n 42) Survival 1 hour Survival discharge
Vasopressin 54 25
Epinephrine 61 33
Stiell 2001
VF/VT (n 188) ROSC Survival admission Survival discharge
Vasopressin 36.8 46.2 17.8
Epinephrine 42.6 (p 0.20) 43.0 (p 0.48) 19.2 (p 0.70)
Wenzel 2004
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Vasopressin-Epinephrine
Patient group (all rhythms) n ROSC Survival admission Survival discharge
Vasopressin 589 24.6 36.3 9.9
Epinephrine 597 28.0 (p 0.19) 31.2 (p 0.06) 9.9 (p 0.99)
Subgroup with PEA n 186 N186 ROSC Survival admission Survival discharge
Vasopressin 104 20.2 33.7 5.9
Epinephrine 82 20.7 (p 0.93) 30.5 (p 0.65) 8.6 (p 0.47)
Wenzel 2004
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Summary BLS HCP

• Lone HCP- Tailor Sequence Actions
• Check for Adequate Breathing
• Open airway in trauma patients
• Avoid Excessive Ventilation (too fast, too much)
• 1 breath Q 8-10secs

• 302 compression ventilation ratio
• Continuous CPR with advanced airway
• Rescuers rotate every two seconds
• Push hard, push fast, allow full chest recoil
• Pulse check gt5 ? 10 seconds