You are doing CPR wrong, or so says Felipe Teran, an ED resuscitation sonographer. Felipe has just started as a Resus/ED attending at University of Pennsylvania.
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Nice work, Felipe! Love the physiologic thought paradig to cardiac arrest.
Very interesting summary of the evidence. I do wonder if instead of a goal of tte or tee on all cardiac arrest patients, we should focus on developing empiric hand positions instead, with a few categories (e.g. aortic and cardiac disease).
Great presentation! If you remember we all used to be taught CPR by tracing the lower rib margins and then placing the heel of hands 1-2 fingers above that imaginary point. I feel that over time, our compression site has be come higher and higher and now our doctors and nurses do compressions almost near the top of the sternum! Thinking on a global scale,, TEE will obviously not be feasible everywhere so we need centers like yours to continue their work on intra-arrest TEE and then publish some recommendations for optimal hand placement, which can be applied in all… Read more »
What’s the optimal hand position? A bit lower on the chest?
I think this was a great presentation and thank you so much for putting this together. The problem in the community setting unfortunately, because of the cost, is obtaining a TEE probe. With that said, I think the concepts are very important, and as long as we use ETCO2 and limit interruption time, I think we can use TTE to try and augment optimal CPR location. Thank you so much again for this post
Maybe we could use the diastolic BP during CPR as a guide for whether we are compressing the right structures (but I imagine NIBP might not be that accurate). Just thinking of those of us who don’t have TEE or invasive BP measurement available.
TTE should also be able to show you if you’re compressing the root.
Very interesting talk, thanks!
Thanks for an excellent review of the evidence of an important topic! However, 13 minutes into the video Felipe shows a diagram over LV stroke volume as a function of AMC distance from the AV. My interpretation of the diagram is that LV stroke volume is lower when the AMC is located towards the LV (negative numbers) and increases as AMC moves more distally, whereas Felipe says it is the other way around (which would be the logical thing). Am I missing something here?
Gabriel Olofsson
Anesthesia resident
University Hospital of Umeå, Sweden
Gabriel, this was a mistake. I misspoke when I said the negative numbers mean closer to the LV. In the figure the negative numbers means the AMC is located at the aortic side, and a positive value means the AMC is at the ventricular side. Hope this clarifies. Good catch.
Felipe Teran
Great presentation! I work at large tertiary care center that has TEE capabilities, but my concern (and one voiced already) is that the majority of places don’t have TEE capabilities. Having said that, I think in the future ED US will become more common place and include TEE. While the TEE aspect is important, I think the physiologic parameter improvements you mentioned (DBP, EtCO2) are perhaps the most consequential. If you could somehow study and perhaps develop a protocol to modify hand placement based on DBP and EtCO2, I think that would be most beneficial to the largest group. You… Read more »
nice and engaging podcast. thanks.
So good. Thanks for sharing. I wonder about availability of TEE in more diverse hospital settings (i.e. not in the ED-ICU or OR) and how feasible it would be to implement from a financial and resource-based perspective but I love the idea.
thank you Felipe, and thank you Scott. first, this pod is terribly frightening, in a way. in one study , 100% of compressions were not over the LV. and, the huge percentage were over the LVOT or aorta; i.e. we have been transiently mechanically cross-clamping the arterial outflow, with each and every compression. (a bit of a slap in the face to the mantra “above all, do no harm”). and for many years. disconcerting is an understatement. as Scott (the guest) suggests in comments above, perhaps TTE , with an eye on the ETCO2 may help with hand/ Lucas position.… Read more »
Briliant and important work. Dr Teran, which position do you find up till now is a better compression point on the chest to have maximal ventricular compression? though of coz not the best as could be shown by TEE ( I saw that that would take times even if the administrator can put resources into training us TEE, yet we can’t wait for that)
Hello, and thanks so much for sharing this mindblowing post with us, Scott and Felipe. I’m left with a painful question (literally): if the optimal place to position hands is over the LV, this means we’re gonna have to start compresing directly on the ribs. Won’t that cause severe damage to the chest wall, rib fractures and perhaps even pneumothorax? I mean, it’s already difficult not to dislocate the sternum or the ribs during CPR, and not seldom we fracture the ribs (especially in the elderly), but we do it right where there’s no lung underneaht to be injured, and… Read more »
Thanks for all your comments and interesting questions. A general theme a I see is people wondering where is the best compression site? the answer is that we don’t have data (at least that I’m aware of) to answer that question. A couple of european studies have looked at whether this patient-specific compression site can be done with ETCO2, but the results weren’t too promising. I think for now what we can say is that based on the evidence we have, we may be harming patients by compressing the wrong structures. Now, what’s the actual clinical impact (beyond these hemodynamic… Read more »
This is a brilliant podcast & the way of the (very near) future IMHO. I’m a cardiac anesthesiologist with preoperative advanced TEE certification frequently called to assist in non-cardiac perioperative arrest and ED resuscitations (less frequently). TEE is attached at my hip. I give it credit for saving at least 2-3 lives/yr. Last one was 2 days ago. No more indirect measurements. You don’t need advanced certification to help save a life. You just need frequent insertion and identification of structures to keep your mad skills, especially during smashing chambers in CPR. My 4-life saving views (you mentioned 3 but… Read more »
Thanks for your insightful comments Laura. I agree with you regarding the Midesophageal Inflow-Outflow (and frequently use this view as well). I trained with (and continue to learn from) cardiac anesthesiologists like you and believe there is much we can learn from cross-training. Running cardiac arrests / hemodynamic decompensation in the OR in perfect controlled environment with TEE in place during surgeries was incredibly helpful and has changed the way I approach resuscitations down in the ED. Every time I teach, I mention that although those 3-4 views have the highest yield, we don’t need to restrict ourselves to learn… Read more »
Great point about the aortic views Felipe. Especially in the unstable and/or trauma patient. Looking forward to meeting you as well. Again, excellent work.
Hi Felipe and Scott, Can you please post the articles mentioned in the presentation to this web-page?
Great presentation. Look forward to hearing about more work on this subject.
Thank you for an excellent podcast. My question was eluded to in one of the other comments; what are you using to measure the blood pressure? Are you taking the time to put in an A-line every time? Do you have any advice/experience about the ability of NIBP or manual palp pressures to measure in a code? I can’t imagine it would be too effective, but you never know.
Interesting study. Our recent CT study may suggest why the area of maximum compression is not over the LV. https://www.ncbi.nlm.nih.gov/labs/articles/28947391/ “All cases demonstrated compression of the sternum, ribs, atria and great vessels. The right and left ventricles were not compressed, but moved laterally and inferiorly, further into the left chest cavity.”
How about this for a theory: the heart is free to move sideways away from the compression force, whereas the aortic root being less mobile experiences greater compression. Could it be that CPR’s effects are from changes in intra-thoracic pressure rather than direct compression of the heart?
Thanks for the great insights on this topic!!
What are your thoughts and experiences on injuries linked to a modified compression-site? I feel like moving away from the sternum towards the actual ribs may cause more secondary injuries and increase the risk for tension pneumos etc.
Whilst it’s great that we now understand the importance of effective CPR, gauging the exact depth of chest compression is extremely difficult for trained professionals, and almost impossible for an untrained bystander.