Improving CPR quality aim of updated AHA guidelines

Compression-only CPR best for out-of-hospital cardiac arrest
Compression-only CPR best for out-of-hospital cardiac arrest

More than half a million people in the U.S. experience cardiac arrest each year and less than 15% survive, prompting the American Heart Association (AHA) to update guidelines for cardiopulmonary resuscitation (CPR), in efforts to improve survival.

"A large gap exists between current knowledge of CPR quality and its optimal implementation," Peter A. Meaney, MD, MPH, of Children's Hospital of Philadelphia, and colleagues wrote in the new consensus statement published in Circulation.

Cardiac arrest survival rates range from 3% to 16% for out-of-hospital cardiac arrest and from 33% to 49% for pediatric cardiac arrest in hospitals, according to background information in the article. Although survival rate are greater than 20% within a hospital setting between the hours of 7 AM and 11 PM, this rate drops to 15% for the remaining hours of the day. 

"Poor-quality CPR should be considered a preventable harm," the researchers wrote. They blamed “variation in monitoring, implementation and quality improvement.”

Meaney and colleagues reviewed existing literature on the subject, including studies, expert opinion and the previous 2010 CPR guidelines from the AHA. Ultimately, the group broke down CPR quality into four areas — metrics, monitoring and feedback, team-level logistics, and continuous quality improvement — while also covering general gaps in existing knowledge and technology. They issued several specific recommendations:

  • Chest compression fraction (CCF) should be greater than 80%. Reduction in preshock pause would help in limiting interruptions to the procedure.
  • Chest compression rates should optimally be between 100 and 120 compressions per minute, as consistent rates above or below that range “appear to reduce survival to discharge.”
  • Chest compression depth of ≥ 50 mm for adults and least one third of the anterior-posterior dimension of the chest in infants and children
  • No residual leaning over the patient's chest between compressions, as this may impede full chest expansion
  • Keep ventilation under 12 breaths per minute, since CCF is a higher priority.
  • Using at least one method to continuously monitor the patient's physiological response to CPR.
To ensure that these tactics are executed, the rescuer and patient should be monitored by a teammate who is able to provide information through visual observation as well as quantitative data via invasive hemodynamic monitoring. 

Using intra-arterial and central venous catheters, monitors should strive to maintain diastolic blood pressure at more than 25 mmHg and ETCO2 at more than 10 mmHg through communication with the rescuer. The patient's pulse is not considered a reliable source for information.

The study also challenged researchers to improve current CPR technology, noting that many aspects of evaluation can only be done after the fact.

Protocol was addressed on larger scales as well. Systems of care, such as EMS teams and hospitals, should develop a coordinated code team response that gives each member involved specific responsibilities.

On a national level, there should be a standard system for reporting CPR quality metrics, whereby data is electronically stored and used later to conduct research to improve CPR quality in the future.

Although generally critical of national CPR performance, the researchers acknowledged that improving technology and research have provided the country with “a tremendous opportunity to improve CPR performance during resuscitation events both inside and outside the hospital.” 

by Walker Harrison, an undergraduate student at Columbia University and editorial intern with Clinical Advisor.

References

  1. Meaney PA et al. Circulation. doi: 10.1161/​CIR.0b013e31829d8654 .
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