MSM 008 Emerging Trends in CPR

“Take some time to learn first aid and CPR. It saves lives, and it works.”

-Bobby Sherman

70’s singer/actor, EMT

            Think back to your last resuscitation. Maybe it was last night, or last week, or last month. Consider the condition the patient was in when you arrived. Was the patient too far gone to be resuscitated? How long was the patient in cardiac arrest before your arrival? What was the treatment prior to arrival? These are all questions we have to ask ourselves before performing CPR, and initiating resuscitation. And yet, despite all of these questions and preparation, the survivability rate of patients with out of hospital cardiac arrest is a dismal 12 percent.[1] With the abundance of new information and technology that seems to emerge every day, it would seem reasonable that the survival numbers would be much higher. So what can we do to improve these numbers? Let’s take a look.

First, we know that the best indicators of survivability in CPR include early CPR and early defibrillation. How that applies to EMS tends to revolve around the availability of resources. Simply put, if we do not have a unit available to perform CPR, the patient will not receive any treatment. So we must, as an industry create an outreach program to lay people encouraging them to learn CPR. Across the country, bystander CPR occurs in approximately 46% of cardiac arrests according to the AHA.  This process has already been started by 36 states that have mandated that students who wish to graduate high school must learn CPR. By 2018, 40 states will have similar laws. [2] This is encouraging, as we can hope that future generations will have more providers willing to perform CPR when they see the need. However, this does not address the current issue.

The simplest solution to the problem of poor survival in cardiac arrest may just be for providers to perform better CPR. This solution may seem simplistic, but as with most things, it may be a simple solution that was so elementary that we all overlooked it. What if we simply analyzed how well we’re doing CPR? In 2016 a team in Wisconsin did just that. When CPR was performed, the monitor that the EMS team was using analyzed the quality of compressions. Then, the team that was involved in the resuscitation was provided a feedback form that showed how effective and consistent their CPR was. The program resulted in an increase in compression depth (4.9 to 5.6 cm), compression rates (111/min to 113/min) and improved the percentage of compressions greater than 5cm (The AHA recommended depth) by more than 60%. Importantly, it was also noted that there was no significant difference in pre-shock pauses.[3] Perhaps simply checking our progress periodically can improve outcomes.

But what if CPR, by its very nature does not lead to positive outcomes? In general patients tend to go into cardiac arrest because of some underlying pathology that we typically cannot see in the field or in the Emergency Department. Additionally, we also know that we cannot effectively perform CPR in the back of a moving ambulance. This brings us to emerging data about the use of extra-corporeal membrane oxygenation (ECMO) devices. In 2016 a study in British Columbia, Canada analyzed the survivability of patients that were placed on ECMO, then called extracorporeal cardiopulmonary resuscitation devices (ECPR) in the setting of refractory cardiac arrest. These patients generally presented in shockable rhythms (31%) and were treated with standard ACLS protocols, with the obvious exception of the ECMO. The data showed that patients that attained ROSC within 8 minutes of resuscitation had a 50% survival, and patients that attained ROSC at 24 minutes had a 90 % survival.[4] This data is phenomenally encouraging in the setting of CPR survival, and should also make us question the existing paradigm of when to terminate resuscitation.

It’s clear that we, as an industry need to take a long, hard look in the mirror and consider how we perform CPR. Are we performing the most basic life-saving procedure available to use well enough? Certainly there’s plenty of data showing that we are not performing at an optimal level. What does seem clear, though is that right now as an industry we kind of suck at performing CPR in a way that is beneficial to the most patients. But, to quote a favorite cartoon “Sucking at something is the first step to being kinda good at something.”

[1] http://cpr.heart.org/AHAECC/CPRAndECC/General/UCM_477263_Cardiac-Arrest-Statistics.jsp

[2] http://schoolcpr.com/about/states-where-cpr-training-is-mandatory-for-high-school-graduation/

[3] Weston, et al. Does an individualized feedback mechanism improve quality of out-of-hospital CPR? Resuscitation Apr. 2017 113:96-100

[4] Grunau, et al. RELATIONSHIP BETWEEN TIME-TO-ROSC AND SURVIVAL IN OUT-OF-HOSPITAL

CARDIAC ARREST ECPR CANDIDATES: WHEN IS THE BEST TIME TO CONSIDER

TRANSPORT TO HOSPITAL?

PREHOSPITAL EMERGENCY CARE 2016;20:615–622