Waarom beademen belangrijk is. 2-3x beter! Overleving Arrest Noord-Holland. Overleving in Europa

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1 60% Overleving Arrest Noord-Holland Ruud Koster Academisch Medisch Centrum Amsterdam 50% 40% 30% 20% % 0% Totale overleving Overleving bij schokbaar 1e ritme Overleving bij geen schokbaar 1e ritme Overleving in Europa Hoe komt de overleving in Nederland zo hoog? 25 7? ? Grote bereidheid BLS uit te voeren Snelle en goede acceptatie van de AED Kwaliteit van BLS onderwijs, al 40 jaar lang! 5?? Basale reanimatie in Europa Statistische analyse: Overleving na reanimatie wereldwijd 48 Overleving met BLS x beter!

2 Probleem groot in de USA: weinig BLS Compression-only CPR Wat zouden de redenen kunnen zijn? 1. Weinig hulpverleners kunnen ventileren 2. Veel hulpverleners doen geen BLS omdat ze geen mond-op-mond beademing willen doen 3. Geen BLS uit angst voor juridische aansprakelijkheid? 4. Beademingen onderbreken de borstcompressies Gebaseerd op jaren dieronderzoek in Tucson (Arizona) Beademing geen voordeel Onderbreking compressies nadelig AHA takes position Retrospectieve analyse van oude gegevens Retrospectieve analyse van oude gegevens 2

3 Omstander BLS Land Omstander BLS Japan (Iwami) : 27% Japan (SOS-Kanto) : 29% USA (Bobrow) : 34% USA (Weisfeldt) : 32% USA, Seattle (Rea) 1980: 22%; 2000: 50% Zweden (Bohm) 1992: 31%; 2005: 50% Noorwegen (Olasveengen) 2007: 59%% Denemarken (Wissenberg) 20: 45% Nederland (Waalewijn/Berdowski) 1995: 53%; 20: >70% Geen BLS willen doen? 1. Herkenning hartstilstand 65% 2. Omstander kan het fysiek niet 20% (Te emotioneel - <%) (Patient te onsmakelijk <2%) Swor Acad Emerg Med 2006 Geen BLS willen doen? 1. Herkenning hartstilstand 65% 2. Omstander kan het fysiek niet 20% Waarom zouden burgers moeten leren beademen? Als je het leert, ben je nog niet verplicht om het te doen Als je het niet leert zal je het nooit kunnen doen (Te emotioneel - <%) (Patient te onsmakelijk <2%) Swor Acad Emerg Med 2006 Waarom zouden burgers moeten leren beademen? Als je het leert, ben je nog niet verplicht om het te doen Als je het niet leert zal je het nooit kunnen doen Hoe lang kunnen we zonder zuurstof? Zuurstof en beademing is nodig Altijd voor niet-cardiale oorzaken van een arrest Altijd voor kinderen Meestal voor arrest met een cardiale oorzaak 3

4 Meursing JACC 1983: 6 honden (alleen abstract) Zuurstof is verbruikt <2-3 minuten Turner Resuscitation 2002 Dorph Resuscitation 2004 Ambulance aankomsttijd 6- minuten Human evidence Compression-only CPR vs. Standard CPR (Bohm 2007) Is de overleving werkelijk similar? Compression-only CPR vs. Standard CPR (Bohm 2007) Compression-only CPR vs. Full CPR (Bohm 2007) Early: 8 minutes Late: >8 minutes Electrical phase Circulatory phase Metabolic phase Three-phase model 4

5 Survival Survival Survival Survival Survival What CPR is delivered? What CPR is delivered? % CPR delivered % CPR delivered CO CPR 20 CO CPR 20 Full CPR All CPR What CPR is delivered? What CPR is delivered? % CPR delivered CO CPR % CPR delivered CO CPR 20 Full CPR 20 Full CPR 15 All CPR 15 All CPR ,0,0 8,0 Survival 12,0,0 8,0 Survival In >30% was informatie over functionele uitkomst onbekend 6,0 4,0 Survival 6,0 4,0 Survival CPC 1+2 2,0 2,0 0, ,

6 Uitkomst Geen BLS CC + ventilatie Comp only BLS Goed: CPC 1+2 (%) (+2.7%) Slecht: CPC 3+4 (%) (+2.5%) Is dit de toekomst? 0% 80% CPC 1+2 CPC % 40% 20% 0% Bobrow JAMA 20 No CPR CC + vent Comp only CPR Dit heeft zijn waarde bewezen Nederland zit in de top 3 van de wereld! Dank zij goede omstander BLS 25 7? ??? Leer en stimuleer borstcompressies met beademing Discussie Er is geen snellere weg naar goede reanimatie! 6

7 For children who have out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander is the preferable approach to resuscitation. For arrests of cardiac causes, either conventional or compressiononly CPR is similarly effective. This nationwide observational study indicates that rescue breathing has an incremental benefit for OHCAs of noncardiac origin, but the impact on the overall survival after OHCA was small The formula of Survival We have to deal mainly with cardiac cases in need for CPR. Conventional CPR Medical Science (Knowledge) 0.9 X Effective Education 0.4 Local Implementation X 0.2 = Survival 0.07 So The formula of Survival the important question then is. CC only CPR Medical Science (Knowledge) 0.5 X Effective Education 0.8 Local Implementation X 0.5 = Survival 0.20 The formula of Survival: which is the best choice? Teach good bystander CPR it helps! Conventional CPR CC only CPR Medical Science (Knowledge) 0.9 Medical Science (Knowledge) 0.5 X X Effective Education 0.4 Effective Education 0.8 Local Implementation X 0.2 = Survival 0.07 Local Implementation X 0.5 = Survival 0.20 triples! Bystander CPR doubles survival Bystander CPR is needed for 5- minutes Arterial oxygen supply lasts 2-3 minutes Education remains critical In class teach full CPR C:V 30:2 Full CPR Medical Science (Knowledge) 0.9 X Effective Education 0.8 Local Implementation X 0.6 = Survival

8 Optimal C:V ratio (ventilation 15 s) Table 2 Lancet CC only 1 Table 3 Avg. survival 42/604 = 6.9% Avg. survival 15/447 = 3.3% Babbs, Resuscitation 2002 Lancet CC only 2 Who did CPR? Survival by provider CPR by CO CPR Full CPR OR (C.I.) Average Lay person 23/342 (7%) 19/362 (5%) 1.3 ( ) 42/704 (6.0%) Off-duty medical worker 4/97 (4%) 11/350 (3%) 1.3 ( ) 15/447 (3.4%) Who did CPR? Survival by provider CPR by CO CPR Full CPR OR (C.I.) Average Lay person 23/342 (7%) 19/362 (5%) 1.3 ( ) 42/704 (6.0%) Off-duty medical worker 4/97 (4%) 11/350 (3%) 1.3 ( ) 15/447 (3.4%) Evenly distributed? CPR by CO CPR (n=439) Full CPR (n=712) Lay person 342 (78%) 362 (51%) Not superior, therefore equal or similar? Off-duty medical worker 97 (22%) 350 (49%) difference not proven treatments are equal confounder: Covariate, not related to variable of interest (compression only resuscitation) Determinant of outcome (survival) Unevenly distributed among groups Non-inferiority analysis would not have rejected inferiority 8

9 New discussion 2008 Survival after cardiac arrest Study (outcome) standard = CC en MMV CC only RR (95% CI) Nagao (Japan) (30 days, good neurologic) Bohm (Sweden) (1 month, good neurologic) Iwami (Japan) (1 year, good neurologic) Bobrow (USA) (survival to discharge) 4% 6% 1.5 ( ) ( ) ( ) ( ) ERC Richtlijnen 20 Recommendations Follow the ERC Guidelines 20 Teach full CPR with ventilations Do full CPR with ventilations Recommend CO CPR for: not willing or able to do ventilations telephone instructed CPR Alle hulpverleners, met en zonder training, moeten borstcompressies geven aan slachtoffers van een hartstilstand. Getrainde hulpverleners moeten ook beademen met een compressie ventilatie (CV) verhouding 30:2. Telefoon-instructies doen BLS met alleen borstcompressies voor omstanders zonder training. AHA Richtlijnen 20. Als borstcompressies zijn gestart, moet een getrainde hulpverlener ook mond-op-mond beademen of met een ballon Gebruik een C:V verhouding van 30 borstcompressies op 2 ventilaties Type of CPR change none 72% 67% 68% 64% 60% full 23% 17% 17% 12% % CC only 5% 15% 15% 23% 30% 9

10 Type of CPR change none 72% 67% 68% 64% 60% -12% full 23% 17% 17% 12% % -13% CC only 5% 15% 15% 23% 30% +25% Type of CPR change none 72% 67% 68% 64% 60% -12% full 23% 17% 17% 12% % -13% CC only 5% 15% 15% 23% 30% +25% Overall survival 3.7% 7.2% 6.7% 6.6% 9.8% +6.1% Is CO CPR the better way? Gordon Ewy Circulation 2008: 1. Scientific evidence remains on low level 2. Severe methodological problems in the design and analysis 3. The only effectiveness study shows modest increase in bystander CPR but no overall benefit of a relevant outcome 4. Compression only CPR is not suitable for children and for patients with a respiratory cause Wat is de vraag van het onderzoek? Therapie onderzoek: Meestal nieuw middel is beter dan oud middel Bewijs: significant beter b.v. nieuw tenminste % beter Soms nieuw middel is gelijk aan oud middel Bewijs: nieuw niet significant slechter dan oud - b.v. nieuw maximaal % slechter Recommendations Do CPR it helps Teach good chest compressions After 2-3 minutes of CPR oxygen is needed Teach ventilations Use AED s for early defibrillation! Evaluate all evidence at ILCOR 20

11 Type of CPR change none 72% 67% 68% 64% 60% -12% full 23% 17% 17% 12% % -13% CC only 5% 15% 15% 23% 30% +25% Survival after resuscitation Overall survival 3.7% 7.2% 6.7% 6.6% 9.8% +6.1% Neuro intact survival 2,4% 5,5% 4,7% 4,2% 3,6% +1.2% Only reporting on patients with a cardiac cause Excluded age <18 yr;non-cardiac cause Requirements for effectiveness study: Interventions in the real world All patients in the community accounted for Meaningful outcome Lay rescuers Off-duty medical personnel Survival 42/604 (6.9%) RR 15/ (3.3%) Survival after resuscitation Study cohort Overall outcome CC and ventilation OR Lay rescuers 6% 4% ns Off-duty medical personnel P = 0.02 P = 0.04 P = 0.02 Non-inferiority design II Survival R cc+mmv = 7.8% Survival R cc only = 6.7% Odds ratio 1. ( ) Overleving kan liggen tussen 5.2% en 8.3% absoluut verschil -2.6% en +0.5% CC Only slechter 7.8% CC Only beter CC only overlevingskans Wat is het maximum nadeel dat we willen accepteren? 0%?0.5%? 1%? 11

12 Survival (%) Main result: survival CC only CC and ventilatio n Overall 6% 4% ns apnea VF Resuscitation < 4 min P = 0.02 P = 0.04 P = 0.02 Survival without and with Basic Life Support First defibrillation (min) No BLS BLS Conclusion on chest compression only CPR Current guidelines 2005 (including C:V ratio 30:2) are adequate Evidence from Lancet paper is insufficient to change guidelines Re-evaluate science in ILCOR Guidelines process 20 Change at ILCOR 2000: practice Compression rate 0/minute 2 respirations in 5 sec Compressions/minute Respirations/minute 5: : Compression rate 0/minute 2 respirations in 16 sec* Compressions /minute Respirations/minute 5: : *Assar Resuscitation 2000 Non-inferiority design I Observational cohort Therapie onderzoek: Meestal nieuw middel is beter dan oud middel Bewijs: significant beter b.v. nieuw tenminste % beter Soms nieuw middel is gelijk aan oud middel Bewijs: nieuw niet significant slechter dan oud - b.v. nieuw maximaal % slechter Confounding confounder: Covariate, not related to variable of interest (cardiac only resuscitation) Determinant of outcome (survival) Unevenly distributed among groups Off-duty medical personnel vs. lay rescuers 12

13 Waarom beademen Survival belangrijk after is cardiac arrest Is Basic Life Support important? Study (outcome) Nagao (Japan) (30 days, good neurologic) Bohm (Sweden) (1 month, good neurologic) Iwami (Japan) (1 year, good neurologic) Bobrow (USA) (survival to discharge) Waalewijn1995 (Holland) Berdowski 2006 (Holland) (hospital discharge) standard = CC en MMV CC only RR (95% CI) 4% 6% 1.5 ( ) ( ) ( ) ( ) Four supportive studies Respons from ERC Type of CPR change none 72% 67% 68% 64% 60% -12% conventional 23% 17% 17% 12% % -13% CC only 5% 15% 15% 23% 30% +25% Overall survival 3.7% 7.2% 6.7% 6.6% 9.8% +6.1% Neuro intact survival 2,4% 5,5% 4,7% 4,2% 3,6% +1.2% Only reporting on patients with a cardiac cause Increase of CC only CPR half from less full CPR Neuro intact survival minimal role of TH? Effectiveness study Interventions in the real world All patients in the community accounted for Outcome neuro intact survival 13

14 Survival (%) Survival (%) Relation of collapse to CPR and defibrillation to survival: simplified model. Survival without and with Basic Life Support 80 No BLS 60 BLS Valenzuela T D et al. Circulation. 1997;96: Copyright American Heart Association, Inc. All rights reserved First defibrillation (min) Waalewijn Resuscitation Survival without and with Basic Life Support No BLS BLS Is ventilation needed during CPR? Pro: Circulatory arrest is not always primary cardiac arrest (drowning, ashyxia, children) Oxygen content decreases rapidly during CPR Carbon dioxide needs to be removed Evidence from time of 5:1 C:V ratio First defibrillation (min) Waalewijn Resuscitation 2001 Valenzuela Circulation 1997 Con Interruption of chest compression decreases CPP Animal evidence suggests improved survival Rescuers hate to do mouth-to-mouth breathing Telephone CPR is better when only CC tought Guidelines 2005: do C:V ratio 30:2 when acceptable Verschillende issues Waarom beademen Chest compressions belangrijk is not/minimally interrupted Pause/onderbrekingen Pre-shock;post-shock;ventilaties Niet willen blazen Kern Resuscitation

15 Survival (%) Type of CPR change none 72% 67% 68% 64% 60% full 23% 17% 17% 12% % CC only 5% 15% 15% 23% 30% Type of CPR change none 72% 67% 68% 64% 60% -12% full 23% 17% 17% 12% % -13% CC only 5% 15% 15% 23% 30% +25% Type of CPR change none 72% 67% 68% 64% 60% -12% full 23% 17% 17% 12% % -13% CC only 5% 15% 15% 23% 30% +25% Type of CPR change none 72% 67% 68% 64% 60% -12% full 23% 17% 17% 12% % -13% CC only 5% 15% 15% 23% 30% +25% Overall survival 3.7% 7.2% 6.7% 6.6% 9.8% +6.1% Overall survival 3.7% 7.2% 6.7% 6.6% 9.8% +6.1% Neuro intact survival 2,4% 5,5% 4,7% 4,2% 3,6% +1.2% Only reporting on patients with a cardiac cause Excluded age <18 yr;non-cardiac cause Requirements for effectiveness study: Interventions in the real world All patients in the community accounted for Meaningful outcome Arrest 2: survival without and with Basic Life Support Waalewijn Resuscitation 2007;73: No BLS 40 BLS First defibrillation (min) 15

16 Survival (%) Survival without and with Basic Life Support No BLS BLS Conclusion Oxygen is needed many minutes before ambulance arrival Compression only CPR has not proven to be equal, and certainly not superior! First defibrillation (min) Studies Ambulances are fast Author-year Journal OR (CI) N= Marwick 1995 Resuscitation 3.5 ( ) 487 Hulik 1997 Resuscitation 2.9 ( ) 251 Waalewijn 2001 Resuscitation 2,5 ( ) 476 Herlitz 2005 Resuscitation 2.0 ( ) 2076 Fridman 2007 Resuscitation 2.0 ( ) 3009 Iwami 2007 Circulation 1.6 ( ) 783 Hinchey 20 Ann. Emerg. Med 9.9 ( ) Daisy 2011 Resuscitation 1.3 ( ) 6360 Abrams 2011 Resuscitation 1.7 ( ) 1156 But are they that fast? 2-3x better survival Meursing JACC 1983: 6 dogs (abstract only) And what about gasping? Compressions also move air 16

17 Human evidence Compression-only CPR vs. Standard CPR (Bohm 2007) Is survival really similar? Compression-only CPR vs. Standard CPR (Bohm 2007) Compression-only CPR vs. Full CPR (Bohm 2007) Early: 8 minutes Late: >8 minutes Electrical phase Circulatory phase Metabolic phase The model should follow the data Three-phase model De wereld heeft eindelijk C-A-B geaccepteerd!

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