High Quality CPR

Antonius Freddy 17
Dept – SMF Emergency Medicine
FKUB – RSSA
• CPR Rate: 100 -120 cpm

• CPR Depth: > 2 inches - <2.4 inches

• Fully release

• Chest compression fraction as high as possible, at

least 60%

• CPR Interruptions < 10 seconds & Pulse Check < 10

seconds

• CPR feedback devices in training and during

resuscitation:
IIa recommendation

• Continuous capnography to verify tube placement

and monitor progress of resuscitation: Class I
recommendation

• Debrief mock codes and actual resuscitations

Chest Compression Depth
 2010 Guidelines: The adult sternum should be
depressed at least 2 inches (5 cm)2.5

Mean Compression Depth (in)

P=0.004
2

1.5

0.5

0
<1 1-1.5 1.5-2 >2 Non-survivor Survivor
Compression Depth (in)

Edelson et al. Resuscitation. 2006; Nov;71(2):137-45 Vadeboncoeur et al. Academic

Emergency Medicine. 2010; 17(s1): #502
 Depth of Compressions: ROC Study

The ROC investigators

demonstrated that
survival was associated
with depth between 4.5-6
cm.

A study showed that

depth > 6 cm often
resulted in injury
 ROSC Requires Perfusion
 Paradis demonstrated that a
coronary perfusion pressure (CPP)
of > 15mmHg is required in order
to achieve ROSC.

 Measurements of manual CPR

generally show average CPP of
~ 12mmHg.

 Foundation of studies that looked

at manual CPR components and
how to improve them.

JAMA. 1990;263:1106-1113.
Chest Compression Rates
Idris et al .showed
that survival to
discharge
correlated with
chest compression
rates between 100 -
120
Rate compression
– New consensus statement puts an upper limit on rate because of
this.
 Pre-Shock Pauses
 Edelson further
demonstrated that pre-
shock pauses impact
shock success.

 Research
demonstrated a near-
linear inverse
relationship between
pause time and shock
success.

Resuscitation. 2006;71;137-145
Pauses Impact Survival

 Cheskes et al reviewing the Resuscitation Outcomes Consortium (ROC)

PRIMED data determined that pause times played a significant role in survival
to discharge.
 In this review, the survival to discharge was significantly improved when the
pre-shock pause time was under ten seconds and the peri-shock pause was
under 20 seconds
Impact of Ventilation

 Aufderheide measured the

impact of ventilation rate in a
swine model.

 Study demonstrated that as

ventilation rate increased
thoracic pressure increased,
impeding flow and causing
CPP to fall.

 More importantly,
hyperventilation resulted in
significant mortality.

Circulation. 2004; 109;1960-1965

Release Velocity and Outcomes
Definitition:
 Fast (≥400 mm/s) = 1574 centi-inches / second
 Moderate (300–399.9 mm/s) = 1181-1570 centi-inches / second
 Slow (<300 mm/s) = 1181 centi-inches / second

Results:
 Fast CCRV was associated with increased survival compared to
slow
 Fast CCRV was also associated with improved favourable
neurologic outcome compared to slow
 There was a 5.2% increase in the adjusted odds of survival for each
10 mm/s increase in CCRV
 Conclusion: CCRV was independently associated with improved
survival and favorable neurologic out-come at hospital discharge
after adult OHCA.
 Release Velocity
 Kovacs et al studies release velocity
and demonstrated that survival and
good neural status correlated with
speed of release.

 Fast CCRV was associated with

increased survival compared to
slow[adjusted odds ratio 4.17 (95% CI:
1.61, 10.82) and moderate CCRV
[adjusted OR 3.08 (1.39, 6.83)].

 There was a 5.2% increase in the

adjusted odds of survival for each 10
mm/s increase in CCRV [adjusted OR
1.052 (1.001, 1.105)].

Resuscitation 2015 Jul;92:107-14

Use of EtCO2
 EtCO2 (capnography) is a class I
recommendation for verification of the
placement of the ET tube.

 EtCO2 is a valuable indicator of ROSC

as values increase dramatically.

 EtCO2 to guide CPR quality is limited

as low ETCO2 values may reflect
inadequate cardiac output, but EtCO2
levels can also be low as a result of
bronchospasm, mucous plugging of
the ETT, kinking of the ETT, alveolar
fluid in the ETT, hyperventilation,
sampling of an SGA, or an airway with
an air leak.

 Guideline 2015 state that

prognostication of futility may
incorporate EtCO2 measures, but
should not be the sole indicator.
 Debriefing

 There is a strong
recommendation to debrief
resuscitation events.

 Edelson et al showed that the

inclusion of CPR feedback and
debriefing increased ROSC and
strong trend to improved
survival.

 Wolfe et al et al measured the

impact of quantitative debriefing
in pediatrics and survival to
discharge and good neurological
outcome showed adjusted odds
ratio of 2.5 and 2.7
respectively. ARCH INTERN MED/VOL 168 (NO. 10), MAY 26, 2008
Crit Care Med 2014 Jul;42(7):1688-95
Crit Care Med 2015; 43:2321–2331.
Compressions in Target
 While average rate and depth are generally good, the
heart wants to see the correct rate and depth in each
compression.

 This is able to be measured with the ZOLL R Series

 This is where generally the CPR quality falls apart as it is

difficult to do this consistently without help.
Data Collected
Rescue breathing

 Once the definitive airway inserted (ETT,

Supraglottic airway) ,rescue breathing should be
delivered 10 x/1’ for all age.
Thank You!