On occasion, I get the honor of being to “asked” to help with my daughter’s homework. It isn’t common, fortunately, as I don’t recall middle school algebra that well, but recently I was emphasizing the fact that you cannot expect excellent results from complicated systems (equations) if you fail to do the basics correctly.

Often we get distracted with “advanced” strategies and techniques. While advanced procedures can be effective, suboptimal performance of the basics will undermine the entire project.  This concept, I think, is easily reflected when we are involved in resuscitations.  Focusing on the choice between lidocaine, procainamide, and amiodarone is fruitless if the team is not performing the basics optimally.  Without question, The Basics are the Best! (These are important to know for everyone… including parents!)

We all know that the American Heart Association has emphasized the focus on the basics, and we recently discussed the need to de-emphasize pulse checks, but let us now look at how to optimize our chest compressions!

What are Quality Chest Compressions

• For pediatrics patients quality chest compressions require:
  • Rate of 100 compressions per min
  • Compression Depth of 1/3 AP diameter
  • Compressions that allow for complete recoil of the chest!
    • This is just as vital as the depth and the rate, but often under appreciated!
    • It is during recoil phase that the heart chambers fill with blood and the coronary arteries have blood flow.

Quality Chest Compressions Matter

• Goal of delivering CPR is Return of Spontaneous Circulation (ROSC) and Maintaining Cerebral Perfusion.
  • Obvious ROSC is important, but survival with good neurologic outcome is the real goal.
• Quality chest compressions can generate good MAP.
  • This is integral to having a chance to provide cerebral perfusion!
  • Sutton et al. showed that quality chest compressions can generate systolic BP >80 and diastolic BP >30!
• Quality chest compressions can lead to improved survival.
  • When compared to suboptimal chest compressions, quality chest compressions have been associated with improved survival in the first 24 hours.
  • Obviously, this does mean overall survival, but you have to start somewhere.

Optimize Chest Compressions

• Since chest compressions are so important, one of the most important roles a team leader has is to ensure they are being optimized.
  • Use a BackBoard!
    • Even with adults this is important, but particularly true in children.
    • Often the compression of the gurney’s mattress will significantly diminish the actual AP compression of the patient!
    • The backboard can be easily overlooked and if not present, all of the efforts are being undermined!!
  • Get the timing down! Use a Metronome!
    • Often it is recommended to do compressions to the beat of a song…
      • But even if we all sing the same song, the tempo of that song can easily be misjudged.
    • Take the guess work out of it… is an automatic timing system.
      • Use a metronome to help define what 100/min is.
      • There is “an app for that.”  Some apps will use your smartphone’s flash to signal that rate… which give nice visual cues to the compressor.
      • There are also “fancy” commercial products available that can give cues to the timing and depth of compressions, but they aren’t free.
  • Use End-Tidal CO2 to provide feedback.
    • Studies show that EtCO2 can be a surrogate maker of blood flow produced during compressions in both adult and pediatric patients.
      • CPR is a low flow state, and as such, EtCO2 becomes less dependent upon CO2 production and ventilation and is more related to Cardiac Output.
      • Since pediatric arrests are usually due to respiratory (or infectious) etiology, do not rely on the initial EtCO2 value.
      • The value is more reliable after 1 min of compressions.
    • Goal EtCO2 of between 10-15 during chest compressions.
      • Can be used as a feedback device… as it indicates quality compressions are being done.
      • If EtCO2 <10, ROSC is unlikely. Double check your quality characteristics!
    • If EtCO2 increases substantially during chest compressions, this likely indicates ROSC.
      • Using this method can help decrease interruptions in chest compressions for “pulse checks.”
      • Just seeing an increase would not lead me to stopping compressions… I’d likely complete that 2 min cycle before checking for pulse.
  • Mandate the Rotate!
    • While we work with many true heroes, this is not a time to allow someone’s self-sacrifice to interfere with quality chest compressions.
      • Even the strongest and biggest person will get tired.
      • The power to do quality chest compressions is similar to that of running or swimming.
      • While the compressor may be a physically fit individual, he/she will not sprint at the same rate the entire time.
    • Studies show there is a measurable and significant decrement in quality of chest compressions at 2 minutes for both adult and pediatric patients!
      • Interestingly, the rate and depth often stays the same, but the compressor begins to lean on the chest.
      • This decreases the chest recoil!!  We cannot have that.
    • Do not ask if the compressor is “ok.”
      • Tell him or her that it is time to rotate rapidly and have the next person prepped and ready to take over without interruption!
      • Even if it is Superman, tell him it is time to rotate for the sake of optimizing your chest compressions!

References