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Refresher Training: The ResQ Trial in Whatcom County Prepared by Janice Lapsansky January 2008 Topics 1 Adult CPR 2 ResQ Trial Refresher Click on this icon to reveal the answers to test preview questions Learning Objectives This is an online EMS continuing education module for EMS providers in Whatcom County. After completing this course you will be able to: 1. Briefly describe the study objectives and your role in the ResQ Trial. 2. List the patient inclusion/exclusion criteria. 3. State the purpose of the randomization calendar and the method your agency uses to insure the calendar is followed correctly each week. 4. Describe the correct performance of standard CPR (with the modified hand position) and use of the AED according to current AHA guidelines. 5. Describe the correct use of the ResQ POD with standard chest compressions during CPR. 6. Describe the correct performance of active compressiondecompression (ACD-CPR) with the ResQ Pump and ResQ POD. Terms ACD-CPR – active compression-decompression cardiopulmonary resuscitation AED – automated external defibrillator cardiac arrest – abnormal heart activity insufficient to produce a pulse chest decompression – chest expansion as a result of natural recoil or ResQ Pump use compression to ventilation ratio – alternating sets of 30 chest compressions and 2 ventilations during adult CPR with an unsecured airway (BVM ventilations) DNR – do not resuscitate ETCO2 – carbon dioxide content of air measured at the end of exhalation impedence threshold device (ITD) – valve that prevents air from entering lungs during the decompression phase of CPR; aka ResQ POD inclusion/exclusion criteria – decision list to determine whether a victim of cardiac arrest meets the qualifications to be enrolled in the ResQ Trial secure airway – a cuffed airway, such as provided by an endotracheal (ET) tube or Combi-tube, and held in place by a tube holder study randomization – pre-determined schedule of CPR method, strictly followed by controlling the availability of study devices on rescue vehicles 1 Adult CPR ABC’s • Open the airway • Check for breathing • Look, listen, and feel • Check for circulation 1 Opening the Airway head-tilt / chin-lift • For all victims unless cervical spine injury is suspected. 1 Opening the Airway head-tilt / chin-lift jaw thrust • Without head extension where cervical spine injury is suspected. If the jaw thrust does not adequately open the airway use the head-tilt, chin-lift, because airway takes priority. 1 Quality CPR w/ BVM • The compression to ventilation ratio is 30:2 • The ventilation rate during CPR is 1 breath every 6-8 seconds Is this faster or slower than the rate of rescue breathing? • Deliver each rescue breath quickly (1 sec) with visible chest rise • Provide immediate chest compressions AHA says: 1 Hand Placement • Use the mid-nipple line for adults and children Rock the heel of the hand off the chest, keeping fingertips on chest wall to maintain hand position. During CPR, how often should the rescuer performing chest compressions be rotated out? 1 AED & Defibrillation Cardiac arrest not witnessed by EMS: When should the defib pads be applied to the patient? • Perform 5 cycles or 2 minutes of CPR before analyzing rhythm Highlights of the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Currents in Emergency Cardiovascular Care. Vol. 16 No. 4, Winter, 2005-2006 1 Defibrillation No stacked shocks No pulse check after shock These measures limit the “no flow time”. Why is it important to reduce the amount of time when compressions are not performed? Single shock will be followed immediately by 2 minutes of CPR, then pulse check, and re-analyze if necessary Defibrillation • EMS-witnessed Arrest: —Use AED first in adult victims when AED is immediately available. What will you do immediately after the first shock is delivered? • Unwitnessed Arrest: — 5 cycles or 2 minutes of CPR, beginning with chest compressions. 1 CPR and Rescue Breathing with a Bag-Valve Mask (BVM) • 30:2 compression to ventilation ratio • Hold tight, two-handed face-to-mask seal • Count compressions out loud (“1 and 2 and 3 and…”) • Pause after 30 compressions for delivery of 2 rescue breaths Because each rescue breath is given more quickly, will you also give a larger volume of air with each breath? 1 Rescue Breathing During CPR with an Advanced Airway • ET tube or Combi-tube • Ventilations at 8-10 times per minute, or approximately every 6-8 seconds • For all victims in cardiac arrest Should you pause chest compressions to deliver breaths after tube placement? 1 Quality of Chest Compressions • Push hard, push fast • Adult compressions must be 1 ½ - 2 inches deep • Standard rate is 100/min • Do not interrupt chest compressions for longer than 10 seconds How will you insure that the heart fills to the greatest extent possible between chest compressions? 1 CPR Success • Provide effective chest compressions (and decompressions) with appropriate timing • Limit no flow time (NFT) – i.e. limit pauses in chest compressions • Manage the airway & apply ventilations correctly (DO NOT hyperventilate!) • Use defibrillation appropriately How often should rescuers practice their CPR skills? 2 ResQ Trial Overview 2 ResQ Trial Research Question Is it possible to provide more effective CPR with one or both of these tools? 2 ResQ Trial Research Question Your participation in the trial will provide critical information about EMS-provided CPR for adult victims of cardiac arrest. The ResQ Trial will analyze: • Return of pulse, for any duration • Patient survival to the emergency department • Patient survival to hospital discharge • Neurologic health (quality of life) after discharge What does AHA say is the most important factor in overall patient outcome following cardiac arrest? 2 Cardiac Pump Component • Blood flow during CPR is due to the direct compression of the heart between the sternum and the spine. How far should the chest be compressed when using the ResQ Pump? 2 “Thoracic Pump” Component • During chest compression, increased pressure in the chest, aided by one-way valves in the heart and veins, causes forward movement of blood through the circulatory system. Approximately how many compressions does it take to move blood from the heart to the brain during CPR? 2 Decompression Phase • The ribs and sternum act as a bellows. • As the chest expands, a vacuum is created. • Blood returns to the heart during this relaxation (decompression) phase. 2 Decompression Phase, cont'd • This small, but important, vacuum (negative pressure) • draws blood back into the chest toward the heart • Increases blood flow into the chambers of the heart 2 Decompression Phase, cont'd • The more blood that returns to the heart (preload)… …the more that is circulated forward (cardiac output) with the next chest compression. • increases blood flow to the brain • increases blood flow through the arteries of the heart “Allowing complete chest recoil after each compression allows blood to return to the heart to refill the heart. If the chest is not allowed to recoil/re-expand, there will be less venous return to the heart, and filling of the heart is reduced. As a result, cardiac output produced by subsequent chest compressions will be reduced.” Highlights of the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Currents in Emergency Cardiovascular Care. Vol. 16 No. 4, Winter, 2005-2006 2 Mechanisms of CPR Tools Begins creation of the vacuum Sustains the vacuum that is created (with a tight facemask seal) = Together, enhance the negative pressure in the chest during the decompression phase of CPR in order to return more blood to the heart. 2 ResQ Trial Calendar • The treatment for the week is decided ahead of time to reduce the chance of bias and to strengthen the results. • The study week begins on Sunday at 8am. S-CPR ACD-CPR+ITD ACD-CPR+ITD S-CPR What is the method used by your agency to insure that the correct devices are stocked on rescue vehicles on Sundays at 8am? 2 ResQ Trial Calendar • Patients will be analyzed according to the treatment that they should have received, not what they actually got. — Follow the schedule exactly — If a “yellow” week, use the ResQ POD pre-loaded on the facemask & ResQ Pump immediately, or within the first 2 minutes of CPR — Do not delay for intubation or other procedures — Report any problems during the hotline call Where can you find the phone number for the ResQ Trial hotline? 2 Inclusion Criteria Adults known or presumed to be ≥ 18 yrs Presumed non-traumatic* cardiac arrest, such as: • • • • • Cardiac etiology Respiratory etiology Stroke Overdose Smoke inhalation • • • • Drowning Burns Metabolic imbalance Seizures *If you are uncertain, presume it is non-traumatic until you determine otherwise. 2 Exclusion Criteria Known or presumed < 18 years Obvious or likely traumatic etiology Penetrating or blunt trauma Pre-existing DNR orders Obvious signs of clinical death (DOA) Family members who request exclusion For ACD-CPR+ITD arm: recent sternotomy (wound not appearing completely healed or, if known, < 6 months) If the patient meets ANY of the exclusion criteria, perform Standard CPR. 2 Study Protocol—3100 patients Cardiac arrest outcome 2 Study Protocol—3100 patients Cardiac arrest outcome S-CPR ACD-CPR + ITD • Randomized by week 2 Study Protocol—3100 patients Cardiac arrest outcome S-CPR ACD-CPR + ITD • Randomized by week – Defibrillation – Intubation – IV & medications • Standard treatment 2 Study Protocol—3100 patients Cardiac arrest outcome S-CPR ACD-CPR + ITD • Randomized by week – Defibrillation – Intubation – IV & medications = • Standard treatment outcome 2 CPR Success • Follow the correct compression rates: — S-CPR: 100/min — ResQPump: 80/min • Allow chest to completely recoil • Do not hyperventilate! • Facemask: 30:2 compressions to vents • Advanced airway: 8-10/min If a pulse cannot be restored, how long should resuscitative efforts last at the scene? 2 Run Follow-up • Complete patient care record accurately: — Attempt to record times (scribe sheet available) —CPR starts/stops —time of Pump and POD use —time of intubation, etc. • Call the research hotline 24/7 — 1-866-640-2832 — for ALL ARRESTS; regardless of whether the patient was entered into the study and regardless of whether resuscitation was attempted (DOAs). 2 Run Follow-up, continued • ResQPOD: place sticker on run report — Discard used ResQPOD, unless there were problems — Re-stock with a new ResQPOD from your agency’s supply. (do not restock from the medic rig) • ResQPump: record number on run report — clean ResQPump and return to service. 2 Standard CPR—Facemask Only • Airway not secured (facemask) — Compress @ 100/min — Pause for breaths — Compression to ventilation ratio 30:2 Is this the correct compression rate? 2 Standard CPR—Advanced Airway • Airway secured (ET or Combi-tube) — Continuous compressions @ 100/min — Do not pause for breaths — Ventilate at 10/min (once every 10 compressions) 2 Two-Person Rescue Breathing with a BVM Maintain a tight, twohanded facemask seal. When it’s time to pause compressions to give breaths, the person doing chest compressions should reach over and squeeze the ventilation bag. 2 ACD-CPR + ITD—Facemask Only • ResQPump & study package with facemask, ResQPOD & sticker • Place ResQPOD & ResQPump within first 2 minutes of CPR •Perform compressions with ResQPump @ 80/min (metronome) •Pause for breaths •Compression to ventilation ratio 30:2 •Compress to 1.5 - 2” with active decompression (use gauge) When should the ResQPOD’s lights be used? 2 ACD-CPR + ITD—Advanced Airway Compress continuously @ 80/min (metronome) Do not pause for breaths Compress to 1.5 – 2” with active decompression (use gauge) Move ResQPOD to airway and turn on timing assist lights Ventilate according to lights or 8-10 breaths/min What should you do if the patient’s pulse returns? 2 ETCO2 Monitoring Place the ETCO2 sensor between the ventilation source and the ResQPOD. 2 Troubleshooting • Timing assist light function is independent of inspiratory impedance valve feature. • If timing assist lights fail to operate or appear to blink at a rate different than 810/minute, disregard the lights, continue using the ResQPOD, and ventilate the patient at 10 breaths/minute. 2 Troubleshooting, cont'd Discontinue ResQPOD if: • Chest does not rise with ventilation • Device appears to malfunction in any way • The POD fills with fluid twice (the airway may be suctioned as needed) 2 ResQPOD Fills With Fluid • Clear fluids or secretions from the ResQPOD by removing it from the airway adjunct and blowing out debris using the ventilation source. • Discontinue use if the device cannot be cleared. • Discontinue use if the ResQPOD fills with fluid more than once. 2 ResQPOD Fills With Fluid, cont'd • You may replace POD with new one (preferred), or discontinue completely. • Suctioning of the airway (w/o fluid in POD) does not require that the POD be discontinued • If you have any problems with the ResQPOD, save in a red bag and return to researcher coordinator. 2 ACD-CPR Compression • Same objective as in standard CPR • 1 ½ - 2” in depth (65 - 90 lbs) • 80 compressions/minute • Body position is critical to avoid fatigue • Do not straddle patient How long should CPR be performed on a patient • Rotate compressor role with an unwitnessed every 2 minutes. cardiac arrest before analyzing with the AED? 2 Troubleshooting ACD-CPR • Suction problems in 10-15% of patients — Reposition, shave, or dry off chest — Continue use, unless distracting When using the ResQPump, how hard should a rescuer pull up (decompress the chest)? • May interfere with AP patch placement — Move patches • Requires 25% more rescuer energy — Rotate every 2 minutes 2 Troubleshooting ACD-CPR, cont'd • Rib fractures — Check placement and continue • Hickey or bruising to chest — Continue • Discontinue use if device appears to malfunction. 2 Cleaning/Reuse • Clean cup with soap and water. • May be cleaned with bleach solution or other disinfectant. • Check gauge for proper calibration. 2 Untrained Healthcare Providers Do not leave the ResQPOD or ResQPump in the hands of healthcare providers who have not been trained in their use. Finally… Give both CPR methods the greatest opportunity to work… Do the best CPR possible! 2 Written Test Click here to return to the start of this presentation… or Close this window and click the ResQ Trial exam link on the main course page. Ventilation During CPR • The ventilation rate during CPR is 1 breath every 6-8 seconds This is slower than for rescue breathing alone. • Rescue breathing (without CPR) is 12 times per minute (every 5 seconds) back AHA says… “Push hard and push fast” • A faster compression rate (that allows full chest recoil) produces the blood pressure required to send blood to the brain and heart muscle. • Adequate compression depth before each shock directly affects shock success – deeper compressions lead to more successful shocks • Resuscitation. 2006; epub, September 16 back 1 Fatigue Factor • Change roles every 2 minutes (5 cycles) • Regardless of whether you feel tired! • Switch quickly to avoid interruptions in CPR back Apply the AED • Apply the AED pads as soon as the patient is determined to be without pulse or respirations. • If the cardiac arrest was not witnessed by EMS (or the downtime is known to be greater than 4 minutes) perform 2 minutes or 5 cycles of CPR before analyzing for a shockable rhythm back 1 Appropriate Defibrillation No stacked shocks No pulse check after shock Do not interrupt CPR for rhythm analysis or defibrillation for long periods of time. During these “no flow times” the brain and heart are not receiving oxygen in the blood. Prolonged no flow times decrease the chance that defib will work! back Following each shock Immediate chest compressions of good quality will supply blood to the heart muscle that will help it respond better to medications and AED shocks back 1 CPR and Rescue Breathing with a Bag-Valve Mask (BVM) Deliver each breath over 1 second, with visible chest rise. DO NOT increase volume! back Rescue Breathing after Intubation DO NOT pause chest compressions to deliver breaths after tube placement. back Decompression Phase Assure that the chest wall recoils completely after each compression in order to maximize the formation of the vacuum that promotes filling of the heart. back Practice your CPR skills frequently Good CPR takes training AND practice Research shows that students continue to show improvement in both knowledge and skills after 4 training sessions Understanding and skills begin to weaken after only 10 weeks following training Rescuers should practice their skills 3-4 times per year Plan to practice with the manikin and other training materials on your own or with a partner for ~10 minutes each month back BLS & ALS work together to save lives! One of the most important factors in overall patient outcome is the quality of CPR. The AHA recently revised their ACLS course, stating that “high-quality CPR is more effective than any ACLS drug. The science tells us that our focus should be on BLS skills to maintain perfusion.” Currents in Emergency Cardiovascular Care. Vol. 17 No. 4, Winter, 2006-2007 back Chest Compression Depth Compress the chest 1 ½ - 2” (65-90 lbs on strain gauge) back 1 Forward blood flow is accomplished beginning with 15 chest compressions, and sustained until compressions are paused for Blood Flow to Vital Organs During Chest Compressions ventilations. Interruption in chest compressions “no-flow time” 0 5 10 15 20 25 30 0 0 0 Compressions Perfusion Perfusion Needed 0 5 back ResQ Trial Hotline You can find the hotline phone number in: • Resource Guide (yellow folder) • Easy-to-Read ResQ Trial Calendar Call the hotline after every cardiac arrest (including peds, trauma victims, & DOAs). Research Hotline: 1-866-640-2832 back 2 Study Protocol EMS performs a minimum of 30 minutes outcome of CPR in all study arms Cardiac arrest S-CPR ACD-CPR + ITD • Randomized by week • 1033 patients per group – Defibrillation – Intubation – IV & medications back = • Standard treatment outcome 2 ResQPOD with an ET Tube The timing-assist lights should be turned on to guide ventilation rate (or 8-10 breaths/min.) only after an advanced airway is placed. back 2 The ResQPOD is a CPR tool The ResQPOD enhances circulation. When pulse returns… back Keep the ResQ POD nearby in case the patient re-arrests. AED • Apply the AED pads as soon as the patient is determined to be without pulse or respirations. • If the cardiac arrest was not witnessed by EMS (or the downtime is known to be greater than 4 minutes) perform 2 minutes or 5 cycles of CPR before analyzing for a shockable rhythm back 2 ACD-CPR Decompression Lift until force gauge reads approx: -20 lbs. back Most common error is failure to actively decompress chest. Compressions at a rate of 100/min. YES! This is approximately 100 compressions per minute. back OR…you can hum the “Staying Alive” song