Verbesserung der CPR mithilfe von Feedbacksystemen Dieses Dokument beinhaltet Abstracts von Studien und liefert Ihnen eine Übersicht über CPR‐ Feedback‐Systeme im direkten Zusammenhang mit der untenstehenden Überlebensformel. Studien belegen, dass CPR‐Feedbacksysteme die Qualität und Effizienz der CPR entscheidend beeinflussen können. Die Referenzen finden Sie am Ende des Dokuments. Aus Aktualitätsgründen haben wir die Abstracts der Studie in englischer Sprache veröffentlicht. Bei Fragen stehen wir gerne unter + 49 89‐864954‐0 oder
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Medical themes: Increased survival with more emphasis on CPR In Seattle1, Rea found that VF survival increased from 33% to 46% with the introduction of a new protocol using a single shock with no rhythm reanalysis or post‐defibrillation pulse checks, and extended the period of cardiopulmonary resuscitation from 1 to 2 minutes. This protocol, which is similar to Guidelines 2010, significantly increased the time for CPR vs defibrillation. CPR – much more than buying time for defibrillation Eilevstjønn and Rea evaluated 1100 episodes of EMS treated cardiac arrest within ROC. Fifty percent of the patients who had the heart restarted were not defibrillated. For those discharged alive, one third were not defibrillated.(ERC2012) These findings underscore the importance of CPR for the treatment of shockable and non‐shockable cardiac arrest.
High chest compression fraction is an independent determinant of survival in VF cardiac arrest Christensen and coworkers from ROC analyzed 506 cases and found highest survival when chest compression fraction was between 61 and 80%. Chest compression fraction is important for non‐VF patients Vaillancourt2 found a trend to increased ROSC with increasing chest compression fraction for non‐VF patients. Poor chest compressions does not circulate adrenaline EMS, trained to Guidelines 2000, used a chest compression depth of only 34mm and a chest compression fraction of only 50% according to Wik 3. When this treatment was given to laboratory pigs, no hemodynamic effect of adrenaline could be detected Short chest compression pauses does not reduce blood pressure Contrary to the previous animal studies, this study in humans demonstrates that blood pressures achieved before the rhythm analysis pause do not necessarily decrease after the pause but may even increase if the duration of the pause is under ten seconds and the quality of CPR is good both before and after the pause.4 Leaning is common and affect patient outcome Fried5 found incomplete release in 91% of the patient cases and in 12% of all pediatric chest compressions. According to Zuercher6, leaning impairs both cardiac output and myocardial blood flow during cardiac arrest. The importance of chest compression depth Suboptimal compression depth was found in half of patients by 2005 guideline standards and almost all by 2010 standards as well as an inverse association between compression depth and rate. A strong association between survival outcomes and increased compression depth could be demonstrated, but no clear evidence to support or refute the 2010 recommendations of >50 mm7. Guidelines 2010 require doubling of compression force. In a study by Wik3, average compression depth without feedback was 34mm and applied force for 34mm depth is about 25kg according to Nysaether8 and Tomlinson9. With guidelines 2010, 50mm chest compression depth will require a force of at 50kg for the average patient. CPR Meter is safe Zuercher10 found that devices like the CPR Meter do not impair hemodynamics during piglet CPR. CPR is safe for victims not in cardiac arrest ILCOR11 state that serious complications among non‐arrest patients receiving dispatch‐assisted bystander CPR occurred infrequently. Of 247 non‐arrest patients with complete follow‐up who received
chest compressions from a bystander, 12% experienced discomfort; only 5 (2%) suffered a fracture; and no patients suffered visceral organ injury.
Education themes: CPR feedback devices is recommended during training A review by Yeoung12 provides good evidence supporting the use of CPR feedback/prompt devices during CPR training as a strategy to improve CPR skill acquisition and retention. The review include a VAM study by Wik13 where subjects who received first 1 initial plus 5 short training sessions shortly thereafter performed better during skill retention testing than those who only received 1 initial training. Oermann14 found that monthly training with a VAM feedback resulted in superior performance vs annual training. These studies supports our strategy of low dose, high frequency training. CPR feedback devices offer just in time training Another study by Wik15 randomized participants to do 3 min CPR on a manikin, both with and without VAM feedback. The group who did CPR first with feedback performed better than the group without feedback. Interestlingly, the group who received feedback first continued to perform at least as good when feedback was turned off. This study supports our strategy that feedback can facilitate just in time training.
Implementation themes: Decay in EMS chest compression quality due to fatigue is rare Half of the providers compressed the chest according to guidelines depth in this study of EMS prolonged resuscitation. Chest compression decay and thereby fatigue within the first two minutes was rare, suggesting that the paramedics were capable of performing good chest compressions but they did not know how hard to push16. QCPR improved CPR Real-time visual and audible feedback by MRx with QCPR altered performance to more closely conform with guidelines.17. However, since there was little room for improvement in CPR quality by these EMS systems (Pittsburgh and Seattle), no improvement in patient outcomes could be detected.
Compression quality is better with CPR meter A study by Skorning18 evaluated CPR Meter. Depth improved from 45% correct to 73% correct and rate improved from 64% to 95% correct. Leaning improved from 4.4% to 0.2%. QCPR feedback improve leaning Niles19 found that automated feedback helped reduce leaning from 50% to 27% of all chest compressions in a series of in‐hospital pediatric arrest. Compression quality is better with a combination of feedback and debriefing. The combination of feedback and debriefing improved compression rate compliance from 45% to 84% and resulted in a doubling of participants providing compressions of both adequate rate and depth, from 29% vs. 64%20. Patient outcome is better with a combination of feedback and debriefing. This study by Edelson21 report an increase in ROSC, a decrease in ventilations per minute and an increase in chest compression depth when MRx with QXPR was complemented with debriefing. Feedback is also helpful in helicopter and moving ambulance Real time automated feedback improves certain aspects of CPR quality in flying helicopters and moving ambulance vehicles. The effect of feedback guidance was most pronounced for chest compression rate.22 Voice prompts in addition to audiovisual feedback did not add value. In this clinical trial23, compression depth and rate, as well as survival was good both with and without voice prompts in addition to visual feedback and a metronome. QCPR require mattress compression When CPR is performed in a bed, mattress compression and hence accelerometer error is was 13mm. When a stretcher was used, the error was 4mm24. These data suggest that about 15mm must be added for CPR in a bed, according to Monsieurs25. RefShare All papers cited are available on RefShare – our library of medical science. To access, go to Knowledgelink, select tools and select Refshare. Here you can search using keywords.
Helge Myklebust, August 2012
REFERENCES 1. Rea TD, Helbock M, Perry S, et al. Increasing use of cardiopulmonary resuscitation during out‐of‐ hospital ventricular fibrillation arrest: survival implications of guideline changes. Circulation 2006;114:2760‐5. 2. Vaillancourt C, Everson‐Stewart S, Christenson J, et al. The impact of increased chest compression fraction on return of spontaneous circulation for out‐of‐hospital cardiac arrest patients not in ventricular fibrillation. Resuscitation 2011;82:1501‐7. 3. Wik L, Kramer‐Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out‐of‐ hospital cardiac arrest. JAMA 2005;293:299‐304. 4. Hoppu S, Sainio M, Huhtala H, Eilevstjonn J, Tenhunen J, Olkkola KT. Blood pressure during resuscitation in man‐The effect of pause during rhythm analysis revisited. Resuscitation 2011;82:1460‐3. 5. Fried DA, Leary M, Smith DA, et al. The prevalence of chest compression leaning during in‐hospital cardiopulmonary resuscitation. Resuscitation 2011;82:1019‐24. 6. Zuercher M, Hilwig RW, Ranger‐Moore J, et al. Leaning during chest compressions impairs cardiac output and left ventricular myocardial blood flow in piglet cardiac arrest. Crit Care Med 2010;38:1141‐6. 7. Stiell IG, Brown SP, Christenson J, et al. What is the role of chest compression depth during out‐of‐ hospital cardiac arrest resuscitation?*. Crit Care Med 2012;40:1192‐8. 8. Nysaether JB, Dorph E, Rafoss I, Steen PA. Manikins with human‐like chest properties‐‐a new tool for chest compression research. IEEE Trans Biomed Eng 2008;55:2643‐50. 9. Tomlinson AE, Nysaether J, Kramer‐Johansen J, Steen PA, Dorph E. Compression force‐depth relationship during out‐of‐hospital cardiopulmonary resuscitation. Resuscitation 2007;72:364‐70. 10. Zuercher M, Hilwig RW, Gura M, et al. A sternal accelerometer does not impair hemodynamics during piglet CPR. Resuscitation 2011. 11. ILCOR. 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2010;81:e1‐e330. 12. Yeung J, Meeks R, Edelson D, Gao F, Soar J, Perkins GD. The use of CPR feedback/prompt devices during training and CPR performance: A systematic review. Resuscitation 2009;80:743‐51. 13. Wik L, Myklebust H, Auestad BH, Steen PA. Retention of basic life support skills 6 months after training with an automated voice advisory manikin system without instructor involvement. Resuscitation 2002;52:273‐9. 14. Oermann MH, Kardong‐Edgren SE, Odom‐Maryon T. Effects of monthly practice on nursing students' CPR psychomotor skill performance. Resuscitation 2011;82:447‐53.
15. Wik L, Thowsen J, Steen PA. An automated voice advisory manikin system for training in basic life support without an instructor. A novel approach to CPR training. Resuscitation 2001;50:167‐72. 16. Bjorshol CA, Sunde K, Myklebust H, Assmus J, Soreide E. Decay in chest compression quality due to fatigue is rare during prolonged advanced life support in a manikin model. Scand J Trauma Resusc Emerg Med 2011;19:46. 17. Hostler D, Everson‐Stewart S, Rea TD, et al. Effect of real‐time feedback during cardiopulmonary resuscitation outside hospital: prospective, cluster‐randomised trial. BMJ 2011;342:d512. 18. Skorning M, Beckers SK, Brokmann JC, et al. New visual feedback device improves performance of chest compressions by professionals in simulated cardiac arrest. Resuscitation 2010. 19. Niles D, Nysaether J, Sutton R, et al. Leaning is common during in‐hospital pediatric CPR, and decreased with automated corrective feedback. Resuscitation 2009;80:553‐7. 20. Dine CJ, Gersh RE, Leary M, Riegel BJ, Bellini LM, Abella BS. Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debriefing. Crit Care Med 2008. 21. Edelson DP, Litzinger B, Arora V, et al. Improving in‐hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern Med 2008;168:1063‐9. 22. Havel C, Schreiber W, Trimmel H, et al. Quality of closed chest compression on a manikin in ambulance vehicles and flying helicopters with a real time automated feedback. Resuscitation 2010. 23. Bohn A, Weber TP, Wecker S, et al. The addition of voice prompts to audiovisual feedback and debriefing does not modify CPR quality or outcomes in out of hospital cardiac arrest‐‐a prospective, randomized trial. Resuscitation 2011;82:257‐62. 24. Nishisaki A, Nysaether J, Sutton R, et al. Effect of mattress deflection on CPR quality assessment for older children and adolescents. Resuscitation 2009;80:540‐5. 25. Monsieurs KG. Chest compression on mattresses: time to achieve sufficient depth. Resuscitation 2009;80:503‐4.