Executive Summary of CPR 2010

Henti Jantung Mendadak(Sudden Cardiac Arrest)Amerika (CDC)kematian CAD/thn 330.000 di luar RS / UGD 250.000 di luar RSInsidens 0,55 kematian/1000 pop/thnEropa (ESC)700.000 kematian/tahun40% Fibrilasi ventrikelIndonesia (Depkes)Penyebab kematian utama sistem sirkulasi (26,4%)

Profil Kesehatan Indonesia 2001 Depkes RI 2002Penyakit Penyebab Kematian Umum di Indonesia16%18,9%26,4%Sistim sirkulasi = henti jantungCourtesy of Arif Mansjoer

Profil Kesehatan Indonesia 2001 Depkes RI 2002

1950 -1960SAFAR Pengendalian jalan napas& Pernapasan buatanKOUWENHOVEN Kompresi jantung tertutup1974American Heart Association Cardiopulmonary Resuscitation (CPR)1993International Liaison Committee on Resuscitation (ILCOR)History of Modern CPR

ILCOR = International Liaison Comittee on ResuscitationAmerican Heart Association AHAEuropean Resuscitation Council ERCHeart and Stroke Foundation of Canada HSFCResuscitation Councils of Southern Africa RCSAAustralian Resuscitation Council ARCResuscitation Councils of Latin America CLARNew Zealand Resuscitation Council NZRC

Circulation 102, 2000Resuscitation 46, 2000International Guidelines 2000 Conference on Cardio-pulmonary Resuscitation and Emergency Cardiovascular Care

BACKGROUNDData2 tentang angka survival sewaktu keluar RS terhadap korban2 henti jantung karena VF di luar RS yg disaksikan sangat rendah yaitu hanya 6% selruh dunia. Dengan catatan hanya sedikit perbaikan setelah guideline thn 2000 di keluarkan. Data2 ini dibuat hanya bberapa waktu sebelum dimulainya konferensi CPR ILCOR2005. Ada 2 penelitian yg dipublukasi sebelum konferensi 2005 menunjukkan buruknya kualitas CPR yg dilakukan baik itu di luar RS atau di dalam RS.

Perubahan2 utama pada CPR 2005

Check and assess - hands-off time = time without chest compression reduce survival100 per menitRatio 15:2

Hands-off time = time without chest compressionRepeatedly assessing the patientInterruption for ventilationOperator delay for CVP, intubation, changing rescuerTime taker by AED for analysisA fall in coronary perfusion pressureA deterioration in waveform of VFA decrease of successful outcome after DC shock

Remove check breath and assess circulationRATIO 30:2(less ventilation)AED

In VF SCA, ventilation NOT AS important as compressionsVQ mismatch (need less Vt)Increases intrathoracic pressureDecreases venous returnPrevents adequate fillingDECREASES CARDIAC OUTPUTGastric insufflation

Why 30:2 or less ventilation?Hyperventilation is bad.

Tekanan intra toraks rata-rataTekanan perfusi koronerAufderheide TP, Sigurdsson G, Pirrallo R, Yannopoulos D, McKnite S, von-Briesen C, et al Hyperventilation-induced hypotension during CPR Circulation. 2004;109:1960-5Penolong profesional pemberian ventilasi berlebih pada tindakan RJP. Hiperventilasi (pada hewan) tekanan intratorakal meningkat, tekanan perfusi koroner menurun, dan angka ketahanan hidup menurun

Why AED?Witnessed vs UnwitnessedWitnessed Collapse//Cardiac Arrest AED firstUnwitnessed arrestCPR first (2 minutes or 5 cycles), then AED

Etiology of sudden cardiac arrestNolan J. ERC Guidelines for Resuscitation 2005-introduction. Resuscitation. 2005; 67 (suppl 1):S3-S6EtiologiCardiac (primary)Heart attack (MCI)Kelaianan jantung lainNon-Cardiac (secondary)InternalPneumonia berat, syok, dllEksternalTrauma, keracunana dll

Etiology of sudden cardiac arrestNolan J. ERC Guidelines for Resuscitation 2005-introduction. Resuscitation. 2005; 67 (suppl 1):S3-S6Etiologi

Henti Jantung100%Henti jantung/paru

Fase Henti Jantung (Weisfeldt & Becker)

Electrical phaseAED firstVF early defibrillation (class I)Each passing minute decreased survival by 8-10%

Survival rate approaching 50%Chicago airport studyAED 10/18 VF case survivalCirculation 1997NEJM 2002

Chicago AirportAED within 1 minute anywhere in the airportSurvival approaching 50% (10/18) for VF

Outcome of Rapid Defibrillation by Security Officer After Cardiac Arrest in CasinosProspective study for sudden cardiac arrest in casinos n=105Survival to discharge 53%90 patients (86%) witnessedCollapse to AED 3.5+2.9Collapse to defibrillation 4.4 + 2.9 minCollapse to defibrillation 3 minSurvival to discharge 74%Collapse to defibrillation 3 minSurvival to discharge 49%NEJM 2000

Tripling Survival From Sudden Cardiac Arrest via Early Defibrillation Without Traditional Education in Cardiopulmonary ResuscitationResult ;354 sudden cardiac arrest in ItalyCirculation 2002;106

Circulatory phaseCPR firstFirst provide oxygen delivery (chest compression/ventilation) followed by defibrillationImmediate vs. delayed counter shockSurvival 24%22%4%30%JAMA 1999;281JAMA 2002;289

Delaying Defibrillation to Give Basic CPR to Patients With Out-of-Hospital VFRandomized trial, n=200Defibrillation at once (group A) vs. 3 min of CPR before defibrillation (group B)JAMA 2003Response time < 5 min (n=81)No difference between group A and BResponse time > 5 in (n=119)

A(n=96)B(n=104PROSC46%56%0.1

A(n=64)B(n=55)P-valueROSC38%58%P

The Science of resuscitation era..

BackgroundThere is a striking disparity in survival outcomes from cardiac arrest across systems of care, with some systems reporting 5-fold higher survival rates than others.Although technology, such as that incorporated in automated external defibrillators (AEDs), has contributed to increased survival from cardiac arrest, no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act. Moreover, to be successful, the actions of bystanders and other care providers must occur within a system that coordi- nates and integrates each facet of care into a comprehensive whole, focusing on survival to discharge from the hospital

Why change CPR?New data has proven strong CPR in the field has improved patient outcomes. Documentation since 2005 has shown that lay rescuer primarily perform CPR with chest compressions only, and that they have similar outcomes to CPR with rescue breathing.Minimizing intervals between chest compressions and delivering a shock, improves chances of shock success and improved patient survival.

Conclusion: Bystander-initiated cardiac-only resuscitaion and conventional CPR are similarly effective for most adult out-of-hospital cardiac arrest. For very prolong cardiac arrest, the addition of rescue breathing may be of some help

Meta-analysis

Conclusion: Available evidence strongly support the superiority of bystander compression-only CPR. Reasons for the best efficacy of chest compression-only CPR include a better willingness to start CPR by bystanders, the low quality of mouth-to-mouth ventilation and a detrimental effect of too long interruptions of chest compressions during ventilation. Based on our findings, compression-only CPR should be recommended as the preferred CPR technique performed by untrained bystander.

Conclusion: Among patients with out-of-hospital cardiac arrest, layperson compression-only CPR was associated with increased survival compared with conventional CPR and no bystander CPR in this setting with public endorsement of chest compressiononly CPR.

So???.

AEDAUTOMATED EXTERNAL DEFIBRILATORRemove open airway and rescue breath time consumingThe old (2005) algorithm

Universal Algorithm CPR 2010

Rescuer Proficiency

Chain of Survival

200020052010Call for helpChest CompressionDefibrillationAdvanced Life SupportPost-Cardiac arrest Care

New Sequence for 2010 Chest compressions, Airway, Breathing (CAB) is the new order of operations from American Heart Association. This applies for adults, pediatrics and infants, excluding newborns. Newborn arrest are most likely respiratory and should use the ABC sequence. Adult Chain of Survival.

Rationale of changes 2010A large number of witnessed cardiac arrest are patients going into a ventricular fibrillation, or pulseless ventricular tachycardia. Early chest compressions and defibrillation are key components to the patients survival. The CAB method allows the responder to save time, and provide blood flow to the heart muscle quickly. A lay person is more likely to give CPR if chest compressions are the priority.

Basic Life SupportHands-Only (Compressions only) CPR for the untrained lay person. Can be guided by dispatcher on the phone.Start chest compression before opening the airway. CAB.Allowing the chest to recoil between compressions with a depth of 2 inches. Rate of 100/min.

BLS Adult Algorithm

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Any unnecessary interruptions in chest compressions, decreases the effectiveness of the CPR. CPR should be continued until return of spontaneous circulation (ROSC) or termination of resuscitative efforts. Healthcare providers should take no longer than a 10 second pulse check to determine if pulses are present. Chest compression and rescue breathing at a rate of 30:2.

Role of the Lay Person RescuerInitial recognition of the victim is imperative to quick treatment. A patient having a cardiac arrest may have gasping respirations or even have seizure like activity. The rescuer should learn through training these are atypical presentations of a cardiac arrest and alert responders to these findings.Lay persons should call EMS when finding unconscious victim and should not attempt to check for a pulse. The lay person should assume that the victim is in a cardiac arrest; 1. suddenly collapses, 2. person is unresponsive, and 3. not breathing normally or not at all.

CPR Devices and TechniquesNo device other than the defibrillator has proven to have long-term survival from in the field cardiac arrest. Electrical Therapies-Pacing in bradycardia, cardioversion and defibrillation for symptomatic tachycardia are all proven methods to help the chain of survival. No precordial thump. CPR prior to defibrillation improves outcomes in cardiac arrest.

Capnography Capnography is recommended for intubated patients.This tool is used as an additional indicator of proper tube placement, monitoring CPR quality and detecting ROSC.

Advanced Cardiac Life SupportNew fifth link in the chain of survival is post cardiac care.Hypothermia treatment studies are showing improvement with neurological, hemodynamic and metabolic function in the ROSC patients. Transportation to most appropriate hospital with comprehensive post-cardiac arrest treatment. Post cardiac care should include prevention, treatment of possible multiple organ dysfunction.

ACLS AlgorithmStart CPR give 02 -Attach monitor/ defibrillator. Call for help!Post-Cardiac CareROSCDrug TherapyAdvanced AirwayTreat Reversible Causes

ST Elevation Myocardial Infarction Prehospital 12 Lead electrocardiogram, with interpretation by EMS providers and information relayed to Base Station.Advanced notification to the receiving hospital are key elements of the treatment and care of a patient having a STEMI.

Pediatric Basic Life SupportAmerican Heart Association reports that 5% to 15% of pediatric cardiac arrest are related to ventricular fibrillation. Studies have also shown that resuscitation from asphyxia benefit from combination of chest compression and ventilations. The CAB method is to be used. Compression only CPR is to be used with bystanders who have not been trained with giving ventilations or do not feel comfortable doing so.

Pediatric Advanced Life SupportUse of the AED with children and infants from ages 1 to 8 years. Rescuer needs peds-dose attenuator system.

Neonatal ResuscitationNo changes in sequence with the neonates. ABCs, unless known cardiac etiology.3:1 compression to ventilation ration.Post resuscitation therapeutic hypothermia. Delay in cord clamping.

Adult StrokeStroke is the third leading cause of death in the United States.Public education about signs and symptoms of stroke, calling 911, are key to the lay person to recognize, in the early hours of the stroke happening. Prehospital programs, and a stroke hospital system are in progress with ICEMA at this time.

Education and Team ApproachEncouraging continuing education with healthcare provider and the lay public. Hands only CPR should be taught to lay persons fearful or unwilling to perform conventional CPR. The AED does not require formal training, but training will enhance the students performance. ACLS training should reinforce the team approach in the code situation.

Terima kasih

Resources/ReferencesAmerican Heart Association, http://www.heart.org. Inland Counties Emergency Medical Agency, http://www.sbcounty.gov/icema. American Stroke Association, http://www.strokeassociation.org.Any questions please contact Patty Eickholt RN, BSN, PHN, MICN, CEN at ICEMA. 909-388-5823.

AHAERC

Check responseShout for helpOpen airwayCheck breathing30 chest compressions2 rescue breaths

DEFIBRILASIAttach AEDSWITCH ON AEDATTACH PADS TO CASUALTYS BARE CHESTANALYSING RHYTHM DO NOT TOUCH VICTIMSHOCK INDICATEDSHOCK DELIVERED FOLLOW AED INSTRUCTIONS302

POSISI RECOVERY

CPR IN CHILDRENTeknik CPR dewasa dapat digunakan pada anak

Kompresi cukup 1/3 tebal dada

AED PADA ANAK Umur > 8 thnGunakan AED dewasa Umur 1-8 thnGunakan pads anak/jika terdapat setting utkanak (jika tidak ada gunakan mode dewasa Umur < 1 thnGunakan jika instruksi dari pabriknya menindikasikan aman

Hands-off time = time without chest compressionRepeatedly assessing the patientInterruption for ventilationOperator delay for CVP, intubation, changing rescuerTime taker by AED for analysisA fall in coronary perfusion pressureA deterioration in waveform of VFA decrease of successful outcome after DC shock

Ann Emerg Med 1994;24:895-906Active Compression-Decompression (ACD)

Impedance Threshold ValveAnesth Analg 2001

Active Compression-Decompression CPR combined with Impedance Threshold Device vs. Standard CPR for Out-of-Hospital Cardiac Arrest ACD + ITD CPR improve vital organ blood flow (>3-fold increased) during cardiac arrestProspective, randomized controlled trial, n=210Circulation 2003;108:2201

Circulation 2000

Triphasic Shocks are Superior to Biphasic Shocks for Transthoracic DefibrillationBiphasic (7.2/7.2 ms) vs Triphasic (4.8/4.8/4.8 ms)Adult, Swine (18-28 kg), VF modelResults

Shock-induced VT and Asystole occurred less often after triphasic shocksJACC 2003

Summary Criticall point in Basic Life SupportPlace greater emphasis on chest compressionAvoid hyperventilationTime-sensitive modelMore sophisticated CPR deviceAED

Setelah insuflasi CO2, ternyata survival tetap rendah, artinya bukan karena hipokarbiavasokonstriksi pemb.darah yang meny. Survival rendah tapi hiperventilasi meny. Intrathorasic pressure yang naik sehingga tek perfusi koroner menurun. *Pada fase sirkulasi, oksigen first.*Grup A defib dulu baru CPRGrup B di CPR sblm defib, ternyata respon di kedua kelompok sama untuk response time < 5 menit.Namun pada response time >5 menit, ternyata kelompok B (CPR dulu baru defib) survival lebih bagus. Kesimpulan : Jadi kalo msh di fase elektrik (< 5 menit sejak cardiac arrest) do AED first! Kalo witness, better AED first.Kalo sdh di fase sirkulasi atau > 5 menit since Cardiac Arrest, do CPR first (kelompok B). Karena AED less usefull.*Similar!!! Between compression-only CPR and Standard CPR (pake tiup2)*Or prefer to compression only!*Based on our findings, compression-only CPR should be recommended as the preferred CPR technique performed by untrained bystander*Conclusion: Among patients with out-of-hospital cardiac arrest, layperson compression-only CPR was associated with increased survival compared with conventional CPR and no bystander CPR in this setting with public endorsement of chest compressiononly CPR.Compression-only CPR

*2000 : dulu gabung pompa dan breath2005 : ada to prevent cardiac arrest (penelitian besar2an pencegahan cardiac arrest, including statintunika intima vaskular mengecil sehingga pd melebar lagi)Pertama kali munculnya istilah RRT (rapid response team)*This applies for adults, pediatrics and infants, excluding newborns. Newborn arrest are most likely respiratory and should use the ABC sequence. Why? Karena 90 % cardiac arrest pd bayi penyebabnya bukan cardiac tapi hipoksia/respiratory problem, sehingga sequencenya tetap ABC*Tidak ada look listen feelTidak ada tiup-tiup*The lay person should assume that the victim is in a cardiac arrest; 1. suddenly collapses, 2. person is unresponsive, and 3. not breathing normally or not at all.***