The 2010 European Guidelines for Cardiopulmonary Resuscitation Bernd W. Böttiger

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1 The 2010 European Guidelines for Cardiopulmonary Resuscitation

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3 Outcome after CPR in Germany ROSC ( Return of spontaneous circulation ) = Kreislaufstabilisierung CPR* ROSC Discharge 1 year *CPR following cardiac arrest of cardiac aethiology (36 months) Böttiger BW et al., Heart 82:674-9, 1999

4 What is the hospital discharge rate following cardiac arrest of cardiac aethiology in Germany? % % 5-10 % Seite 4

5 Outcome after CPR in Germany ROSC ( Return of spontaneous circulation ) 350,000 unsuccessful CPR attempts/ year in EU cerebral / myocardial damage CPR* ROSC Discharge 1 year *CPR following cardiac arrest of cardiac aethiology (36 months) Böttiger BW et al., Heart 82:674-9, 1999

6 CLOSED - CHEST CARDIAC MASSAGE W. B. Kouwenhoven J.R. Jude G. Knickerbocker JAMA. 1960;173(10): Seite 6

7 ERC 2005: Main Issue: Compressions * as early as possible * Any interruption: prognosis * Reality: 50% CPR = compressions * Quality makes the difference Seite 7 ERC, Resuscitation 67 Suppl 1:S1-S189, 2005 ILCOR, Resuscitation 67: ,

8 ERC 2005: Main Issue: Compressions * as early as possible * Any interruption: prognosis * Reality: 50% CPR = compressions to give ALL is the * Quality makes the difference intervention that helps. Seite 8 ERC, Resuscitation 67 Suppl 1:S1-S189, 2005 ILCOR, Resuscitation 67: ,

9 Guidelines 2000 vs. Guidelines 2005 Out-of-hospital cardiac arrests with cardiac etiology Guidelines 2000 Guidelines 2005 Patients (%) ROSC Discharged ROSC Discharged ROSC Discharged VF Asystole PEA Seite 9 Steinmetz et al., Acta Anaesthesiol Scand 2008

10 Guidelines 2000 vs. Guidelines 2005 Dailey et al ROSC Hospital Discharge /75 29% 3/75 4% /65 17% 3/65 5% /58 41% 6/58 10% /58 43% 7/58 12% /64 38% 14/64 22% Seite 10

11 Australian Resuscitation Council Seite 11

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13 The Network of National Resuscitation Councils in Europe Seite 13 To preserve human life by making high quality resuscitation avai To preserve human life by making high quality resuscitation available to all

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15 Key Studies for 2010 Compression Depth and Primary Outcome 2010: to give Push ALL hard is stilland the intervention intensively that helps. and with minimal pauses before and after defibrillations Seite 15 Resuscitation 71:283-92, 2006

16 Key Studies for 2010 Relationship of Compressions and Ventilation? Is effective CPR possible without ventilation? Is ventilation interferring with cardiac output during CPR? Seite 16

17 Key Studies for 2010 Compression (CC) + Ventilation vs. Compression Only 3 min untreated VF + 10 min BLS compression No Flow only is not No CPR Impedance threshold valve (ITV), to inhibit passive ventilation CC : Vent. = 2 : 30 useful in this model. CC only Seite 17 Dorph E, Wik L et al., Resuscitation 60:309, 2004

18 Key Studies for 2010 Interruption of CPR for Ventilation: Negative Haemodynamic Effects on CPP interruptions of CPR CPP should be minimised. First 2 CC Last 2 CC Seite 18 Berg R, Sanders A, et al. Circulation 104:2465, 2001

19 Oxygene reservoir Theory Oxygene reservoir Reality EMS arrival on scene Collapse Minutes Seite 19 Rea T, ILCOR Dallas 2010

20 N=1300 all these studies are on telephone-guided CPR. N=1900 Seite 20

21 Key Studies for 2010 Compression AND Ventilation in BLS? Rudy W. Koster, unpublished analysis Olasveengen Telephone-CPR; randomised Iwami Bohm Nagao Bobrow Bystander-witnessed arrest Seite 21 Hüpfl et al., Lancet, 2010

22 - 13,769 out-of-hospital cardiac arrest - 4,403 (32.0%) received bystander CPR; no AED applied (2.1%) AED applied - Overall survival to hospital discharge: 7% - Survival: 9% (382 of 4,403) with bystander CPR and no AED - Survival: 24% (69 of 289) with AED application - Survival: 38% (64 of 170) with AED shock delivered - Multivariable analyses: AED application odds ratio: 1.75; p=0.002 AED application by bystanders seems to save 474 lives / year Seite 22 J Am Coll Cardiol 2010;55:

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24 BLS in Adults (ERC 2010) Decision to start BLS: Person does not react & no normal breathing Compression only fatal in case of: longer Start withcpr, COMPRESSIONS asphyxia, children Ventilation, if trained and willing to give Compressions : ventilation = 30 : 2 + AED Main Issue: Hard Compressions Seite 24

25 ALS in Adults (ERC 2010) Start with 30 compressions Compression : ventilation = 30 : 2 Compression depth 5-6 cm / 100 (- 120) / min CPR until defibrillator is in place + charged Avoid any interruptions + change every 2 min Main Issue: Hard Compressions Seite 25

26 ALS in Adults (ERC 2010) Intubation of the trache, if trained + alternatives CapnoGRAPHY Ventricular fibrillation (VF): 1x defibrillation Series of 3 defibrillations only if * VF during PCI * VF during/ after cardiac surgery * VF witnessed and defibrillator immediately available Main Issue: Hard Compressions Seite 26

27 Key Studies for 2010 Study questions: Does i.v. medication during CPR has any impact on survival? Do we need to introduce an i.v. line during CPR? Seite 27

28 Results: 350,000 1,183 patients, fatal 851 randomised CPRs / year EU 418 i.v. line, 433 NO i.v. line 2% = 7,000 patients / year Discharge rate 10.5% vs. 9.2% (p = 0.61)? ROSC rate 40% vs. 25% (p < 0.001) Hospital admission 43% vs. 29% (p < 0.01) 8.1% 9.8% ICU admission 30% vs. 20% (p < 0.01) Seite 28

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32 Doubling of survival with adrenalin - Would it be ethical to proceed? Let us give adrenaline, it helps Seite 32

33 A Physician on board the advanced life support unit has a clinical impact on outcome of witnessed patients with OHCA Japanese Circulation Society Resuscitation Science Study (JCS-ReSS) Pt. Cardiac Arrest witnessed cardiac cause Pt Pt Pt Pt Pt Pt non cardiac cause Physicians make the difference: this is NOT in the Guidelines unwitnessed 9413 (11% ROSC) 976 (28% ROSC) 8420 (9% 1 M) 602 (18% 1 M) Seite (6% CPC1-2) 372 (11% CPC 1-2)

34 ALS in Adults Drugs 2010 i.v. line, alternatively: intraosseus line Adrenaline 1 mg / 3-5 min (in VF start after 3. defibr.) Amiodarone 300 mg in VF Thrombolysis in suspected pulmonary embolism Lipid Resuscitation in case of LA-intoxication Main Issue: Hard Compressions Seite 34

35 ThROmbolysis In Cardiac Arrest Randomisierte kontrollierte Multicenterstudie Standardtherapie vs. Standardtherapie + Plazebo + Thrombolyse Patienten 60 Zentren / 11 Länder Status: 958 Patienten ( ) Seite 35 Spöhr F, Böttiger BW. New Eur Engl J Clin J Med Invest 359: , 35: ,

36 Tenecteplase (n = 525) Placebo (n = 525) p 30 day survival ROSC 14.7% 55.0% 17.0% Pulmonary embolism: 2 / 20 vs. 0 / % 24 h survival 30.6% 33.3% Symptomatic ICB 0.8% 0.0% 0.13 Other bleedings 7.7% 6.4% 0.48 Seite 36 Böttiger BW et al., New Engl J Med 359: , 2008

37 after ROSC SaO 2 = 94-98% Seite 37 Kilgannon et al., JAMA, June 2, 2010, Vol 303, No. 21

38 Seite 38 Unconscious adult patients with spontaneous circulation after out-ofhospital cardiac arrest should be cooled to 32 C to 34 C for 12 to 24 h when the initial rhythm was ventricular fibrillation. ERC 2010: many of the accepted predictors of poor outcome are unreliable if the patient has been treated with hypothermia. Such cooling may also be beneficial for other rhythms or in-hospital cardiac arrest. ERC 2005: and children ERC 2010: and newborns Circulation 108:118-21, 2003

39 Keith Lurie et al. 2010, AHA ReSS Meeting Chicago Seite 39

40 Post Cardiac Arrest Treatment Must Start Out-of-hospital Seite 40

41 Induction of cooling during CPR? 200 patients, European multicenter study, witnessed arrest, out-of-hospital, cardiac origin (PRINCE Trial) Intervention: RhinoChill during CPR vs. Controls, ALL patients: hypothermia in the hospital Cooling already during CPR? Cooling during CPR Controlle Survival rate 44 % 31 % Good neurology (CPC1/2) 34 % 21 % Target temperatur with RhinoChill 207 min earlier Seite 41 Castren M et al. Circulation 122: , 2010

42 Prognostic Factor PCI Seite 42 Olasveengen et al. Resuscitation 2009

43 Hypotherma & PCI The Combination is the Success Seite Patienten Knafelj et al. Resus. 2007

44 ALS in Adults Summary Compressions : ventilation = 30 : 2 minimal pauses Compression depth = 5-6 cm / / min Capnographie / drugs Mild therapeutic hypothermia Coronary interventions - PCI SOPs Main Issue: Hard Compressions Seite 44

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46 Th We can save 100,000 lifes per year in the EU Seite 46

47 Children 5 Beatmungen initial 15:2 CPR first, wenn alleine an der Einsatzstelle 2 min Zyklus Medikamente wie Erwachsene Defibrillation mit 4 J/kg Seite 47

48 Newborns Seite 48

49 International Consensus Conference on ECC and CPR Science with Treatment Recommendations (4 years) questions / worksheets delegates from 30 countries - Treatment recommendations, evidence-based - new ERC, AHA etc. Guidelines online 18. October 2010 Seite

50 ILCOR Conflict of Interest Policy Seite 50

51 Implementing the guidelines: Courses Seite 51

52 ILCOR CoSTR 2005 Rescuers should be encouraged to do compression-only CPR if they are unwilling to do airway and breathing manouvres or if they are not trained in CPR or are uncertain how to do CPR. Researchers are encouraged to evaluate the efficacy of compression-only CPR. Seite 52

53 Consensus on science statement: example from 2005 Seite 53

54 Treatment recommendation: example from 2005 Seite 54

55 ERC Guideline: 2005 example Seite 55

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58 CPR: Kontinuierliche Verbesserung Bezeugter Kollaps, Kammerflimmern, kardiale Ursache n = 1733 / 8782 Seite 58 Iwami T et al., Circulation 119: , 2009

59 EED Projekt: CPR Ergebnis ALS, Paramedics (UK) Notärzte (D) Überlebensrate [%] Bonn-North Birmingham, Coventry, West-Midlands # Prospektive Studie 40 45,2 40,4 29,4 Seite ,4 10,7 6,04 14,7 3,99 ROSC Admission 24 h survival Discharge ROSC Aufnahme 24 h Überleben Entlassung CPR-Erfolg entsprechend dem Utstein style, alle Rhythmen, *p<0,01, CHI²-Test Birmingham vs. Bonn Fischer, Resuscitation 1997 (n=918, ; CPR Inzidenz: 64 / Einwohner / Jahr) # Robinson, Eur J Anaesthesiol 1998 (n=3380, ; CPR Inzidenz: 62 / Einwohner / Jahr) Fischer M et al., AINS 38: , 2003

60 Seite 60 Circulation. 2010;122:

61 Induktion der Hypothermie während CPR 200 Patienten, europäisch multizentrisch beobachteter Kollaps prähospital kardiale Genese Intervention: RhinoChill während CPR vs. Kontrolle 182 Patienten randomisiert alle Pt. wurden gekühlt Kühlung während CPR Kontrolle Krankenhausentlassung 43,8 % 31,0 % gute Neurologie 34,4 % 21,4 % Zieltemperatur mit RhinoChill 207 min früher erreicht Seite 61 Castren M et al. Circulation, Circulation. 2010;122:

62 SOPs nach CPR Warum? Hypothermie Volumen Insulin ab BZ 180 md/dl Elektrolyte Revaskularisation Seite 62 Sunde K et al. Resuscitation 2007

63 SOPs nach CPR Warum? Effect of optimal postresuscitation care on survivors of OHCA Kim et al AHA ReSS Meeting Chicago 1299 Pt. ICU ICU plus SOP Discharched 27 % 56% CPC % 54% OR 2,27 SOP: Reperfusion, Hypothermie, CABG, Pacemaker Seite 63

64 FAZIT Schon wieder alles anders? Nein, ABER gute Qualität Adrenalin (i.v. oder i.o., nicht endotracheal) / kein Atropin gute Rettungsdienstpersonal / Notärzte SaO % PTCA während / nach CPR milde Hypothermie für alle SOPs Kapnographie Seite 64

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