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Refresher Training: Adult CPR and the ResQ Trial in Whatcom County Prepared by Janice Lapsansky July 2009 Topics 1 Adult CPR 2 ResQ Trial Refresher Click on this icon to reveal the answers to embedded 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 AHA guidelines. 5. Describe the correct performance of active compressiondecompression (ACD-CPR) with the ResQ Pump and ResQ POD, including methods of troubleshooting difficulties. 6. Describe the information needed to complete the hotline report. 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 exhaled at the end of exhalation impedence threshold device (ITD) – a 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 King-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 as airway takes priority. 1 Quality CPR • The compression to ventilation ratio is 30:2 • The ventilation rate during CPR is 1 breath every 6-8 seconds • Deliver each rescue breath quickly (1 sec) How will you know that your rescue breath is effective? • Provide immediate chest compressions The rate of chest compressions with a pair of hands is … 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. Are broken bones an expected consequence of CPR? 1 AED & Defibrillation Cardiac arrest not witnessed by EMS: • Start compressions IMMEDIATELY • Perform 5 cycles or 2 minutes of CPR before analyzing rhythm • Resume compressions immediately after any shock. Do I check for a pulse right after I deliver a shock? 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 This reduces the “no flow time”. Why is this important? 1. 2. 3. 4. single shock 2 minutes of CPR pulse check re-analyze if no pulse Defibrillation • EMS-witnessed Arrest: —Use AED first in adult victims when AED is immediately available. Is there a “rule of thumb” about when to intubate the patient? • 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 2-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 How can I get the best seal using the King facemask provided in the study packs? 1 Rescue Breathing During CPR with an Advanced Airway • ET tube, Combi-tube, or King-tube • Ventilations at 8-10 times per minute, or approximately every 6-8 seconds • For all victims in cardiac arrest Do you pause chest compressions to deliver breaths after tube placement? 1 Quality of Chest Compressions during Standard CPR • Push hard, push fast • Adult compressions must be 1½ - 2 inches deep • Rate for Standard CPR is 100/min • Do not interrupt chest compressions for more than 10 seconds How will you insure that the heart fills to the greatest extent possible between chest compressions? 1 Successful CPR • All sites have measured an increase in successful resuscitations. • The improved outcome for our patients could be due to • • • • more frequent CPR training, better Standard CPR, CPR with the ResQ Pump and ResQ POD, or all three of these reasons! • We do know that rescuers are doing a great job at • limiting pauses in chest compressions • managing the airway (facemask seal, rate and depth of rescue breaths) • using the AED How often should rescuers practice their CPR skills? 2 ResQ Trial Refresher 2 ResQ Trial Research Question Is it possible to provide more effective CPR with one or both of these CPR 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 • Imagine compressing the heart between the sternum and the spine while you push down on the chest. • This takes 1½ -2 inches for an adult during Standard CPR. How far should the chest be compressed when using the ResQ Pump? 2 “Thoracic Pump” Component • One-way valves in the heart and veins cause forward movement of blood through the circulatory system when pressure increases in the chest. Approximately how many compressions does it take to move blood from the heart to the brain during CPR? 2 Decompression Phase • The “respiratory pump” (movement of the chest during inhalation) helps return blood to the heart normally by creating a vacuum. • During CPR, the ribs and sternum act as a bellows, returning blood to the heart as the chest recoils/expands. (continued…) 2 Decompression Phase, cont'd • This small but important vacuum (negative pressure) developed in the chest • draws blood back into the chest and heart, • increases coronary artery blood flow, • decreases intracranial pressure and increases blood flow to the brain during CPR! Note: The ResQ Pump is designed to create this vacuum more effectively than chest recoil alone when using a pair of hands. 2 Decompression Phase, cont'd • The more blood that returns to the heart (preload)… …the more that is pushed forward (cardiac output) with the next chest compression. What are the two components of cardiac output that CPR should attempt to duplicate? “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 these CPR Tools Begins creation of the vacuum Sustains vacuum that is created = Enhance the negative pressure in the chest during the decompression phase of CPR in order to return more blood to the heart. 2 ResQ Pump Metronome (80 bpm) Force Gauge Suction Cup Handle 2 Airflow Through the ResQPOD during CPR Compression Ventiliation 2 Airflow Through the ResQPOD during CPR Because the ResQ POD uses a valve to control airflow, it is also known as … 2 ResQ Trial Calendar • The method of CPR is decided for the week 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 Know the method used by your agency to insure that the correct devices are stocked on rescue vehicles at the start of each study week. 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 — Implement devices within the first 2 minutes of CPR — Do not delay CPR for intubation or AED — Report any problems during the hotline call What is a randomization error? 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 Lightning/Electricity *If you are uncertain, presume it is non-traumatic until you discover 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, follow traditional SOPs. 2 CPR Success • Follow the correct compression rates: — S-CPR: 100/min — ACD-CPR: 80/min • Allow chest to completely recoil • Do not hyperventilate! • Facemask: 30:2 compressions to vents • Advanced airway: 8-10 vents/min • Rotate compressor every 2 minutes! If a pulse cannot be restored, how long should resuscitative efforts last at the scene? 2 Standard CPR—Facemask Only • Facemask BVM ventilations — Compress @ 100/min — Pause for breaths — Compression to ventilation ratio 30:2 2 Standard CPR—Advanced Airway • Airway secured (ET, Combi-tube, or King-tube) — Continuous compressions @ 100/min — Do not pause for breaths — Ventilate at 8-10/min (1 breath about every 6-8 seconds) King tube 2 ACD-CPR Compression • Same depth as in standard CPR • Compress the chest 1 ½ - 2” (65-90 lbs on strain gauge) • 80 compressions per minute • Body position is critical to avoid fatigue • Do not straddle patient How long should CPR be performed on a patient with an unwitnessed cardiac arrest before analyzing with the AED? 2 ACD-CPR + ITD - Facemask Only • Place ResQ POD & ResQ Pump within first 2 minutes of CPR • Perform compressions with ResQ Pump @ 80/min (metronome) •Pause for breaths •30:2 compression to ventilation ratio How do I avoid fatigue and injury while performing ACD-CPR? 2 Two-Person CPR Stretch the cuff on the facemask to improve the seal. Hold in place by using the fingers of both hands to bring the jaw to the facemask (rather than pushing the facemask down onto the face). When it’s time to pause compressions to give breaths, the person doing chest compressions reaches over to squeeze the ventilation bag. 2 ACD-CPR + ITD—Advanced Airway Compress continuously @ 80/min (metronome) Do not pause for breaths Compress 65-90 lbs (use gauge) with active decompression (-20 lbs) Move ResQPOD to airway and turn on timing assist lights Ventilate according to lights or 8-10 breaths/min What do I do if the timing lights don’t turn on? 2 ETCO2 Monitoring Place the ETCO2 sensor between the ventilation source and the ResQPOD. 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 frequently 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 Run Follow-up • 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 Call to the Research Hotline • 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. —Signs of increased LOC during CPR • 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 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 all victims of cardiac arrest the best chance of survival… Thank you for your teamwork & commitment! 2 Written Test Click here to return to the introduction page and the link to the written test. Ventilation During CPR AHA guidelines call for 500cc tidal volume (the same as for an adult at rest) • WATCH FOR THE START OF CHEST RISE • The ventilation rate during CPR is 1 breath every 6-8 seconds • This is slower than for rescue breathing alone. back About Compression Rate… “Push hard and push fast” • Compress at the rate of 100/minute in S-CPR • Allow full chest recoil • Rotate compressors every 2 minutes to avoid fatigue back 1 Risk of Fractures during CPR • In adults, reports of rib fractures from S-CPR range from 13 to 97%, and of sternal fractures from 1 to 43%. • ACD-CPR has been reported to cause rib fractures in 4-87%, and sternal fractures in 0-93% of cases. Resuscitation 2004, vol. 63, no3, pp. 327-338 Reduce the risk of serious fractures during ACD-CPR by using the strain gauge as a guide: compress 65-90 lbs; pull up -20 lbs. back Using the AED • Apply the AED pads as soon as the patient is determined to be without pulse or respirations. • If the arrest was not witnessed by EMS, analyze after 2 minutes (5 cycles) of CPR • Resume compressions immediately • Do not pause to check for a pulse after delivering a shock. back 1 Appropriate Defibrillation No stacked shocks No pulse check after shock During “no flow times” the brain and heart are not receiving oxygen in the blood. 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 Securing the Airway Perform chest compressions with a 30:2 compression to ventilation ratio for 2 minutes first! The head tilt-chin lift with a good 2-handed face mask seal will provide adequate ventilations in most cases. Do not delay or interrupt compressions early in CPR for a secure airway. back 1 CPR and Rescue Breathing with a Bag-Valve Mask (BVM) Stretch out the cuff on the King facemask to improve the seal. Hold in place with 2 hands. When squeezing the bag, bring the fingertips of one hand together. DO NOT increase volume! back Rescue Breathing after Intubation DO NOT pause chest compressions to deliver breaths after tube placement. Attempt to time ventilations between chest compressions during CPR. back Decompression Phase Maintain contact with the skin at your fingertips while you lift the heel of your hand off the chest. This will assure that the chest wall recoils completely after each compression and maximizes the formation of the vacuum that promotes filling of the heart. back Practice your CPR skills frequently Good CPR takes training AND practice Students continue to show improvement in both knowledge and skills after 4 training sessions Knowledge and skills decrease only 10 weeks after completion of training Rescuers should practice at least 3 times per year 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 w/ ResQ Pump Center the ResQ Pump at the mid-nipple line of the sternum. Compress the chest using the strain gauge as a guide: 65-90 lbs back 1 Blood flow is accomplished beginning with 15 chest compressions, and sustained until compressions are paused for ventilations. Blood Flow to Vital Organs During Chest Compressions Interruption in chest compressions 0 5 10 15 20 25 30 0 0 0 Compressions Perfusion Perfusion Needed 0 5 back Randomization & Other Errors A Protocol Deviation occurs & is reported whenever… • The pump and pod are not used on a patient who should have received ACD-CPR (during a yellow week) • The pump and pod are not used within the first 2 minutes of CPR • The pump and pod are used on a patient who should have received Standard CPR (during a purple week) • The Pod is not removed from the airway after a pulse returns • The Pod is not returned to the airway after the patient rearrests • A call to the hotline is missed or forgotten 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 3 ResQ POD Troubleshooting The timing assist lights are independent of inspiratory impedance function. • If timing assist lights fail to operate or appear to blink at a rate different than 10/minute, keep POD in place and ventilate the patient at 10/minute • approx 10:1 compression to ventilation ratio during S-CPR; or 8:1 during ACD-CPR • Discontinue use (and replace with 2nd ResQ POD) if: • Chest does not rise with ventilation • Device appears to malfunction in any way back AED • 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 • Apply the AED pads as soon as the patient is determined to be without pulse or respirations. back 2 ACD-CPR Decompression Lift until force gauge reads approx: 20 lbs. back Most common error is failure to actively decompress chest. The 2 components of Cardiac Output High quality CPR must focus on • Heart Rate (HR) • Compress the chest at 100x/min in standard CPR • Compress the chest with the ResQ Pump at 80x/min • Stroke volume (SV) • The heart must fill adequately between compressions • negative pressure created as the chest expands returns more blood to the heart, so the next chest compression is more effective! Adequate HR and SV ensure adequate perfusion of back the brain and coronary circulation 2 The ResQ POD is also known as an Impedence Threshold Device (ITD). Ventilation Port 2 Timing Assist Lights Flash @ 10/min Promote proper ventilation & compression rate Timing Assist Lights ON/OFF Switch Turns timing assist lights on & off Atmospheric Pressure Sensor System Provides selective impedance to inspiratory air flow Safety Check Valve Enables inspiration @ -10 cmH2O with spontaneous respiration Patient Port back Avoid fatigue and injury… Rock your body back and forth, bend at the waist, keep arms straight Rotate the compressor every 2 minutes! back