Download Medic One/Emergency Medical Services

Adult CPR and the
ResQ Trial in
Whatcom County
Prepared by
Janice Lapsansky
January 2009
Topics
1
Adult CPR
2
ResQ Trial Overview
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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 the
recent 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 exhaled 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
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 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
These measures reduce “no flow time”. Why is it
important to reduce the amount of time when
compressions are not performed?
Single shock will be followed 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.
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
Because each rescue breath is given quickly, over 1 second,
how do you avoid giving too large a volume?
1
Rescue Breathing During CPR
with an Advanced Airway
• ET 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 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 (rate and depth)
• 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
• 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
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.
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 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
Compression
Ventiliation
2
Airflow Through the ResQPOD
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 for intubation or other procedures
— 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
*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
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 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 objective as in
standard CPR
• 80 compressions/minute
• Body position is critical to
avoid fatigue
• Do not straddle patient
• Rotate compressor role How long should CPR be
every 2 minutes.
performed on a patient
with an unwitnessed
cardiac arrest before
analyzing with the AED?
2
ACD-CPR + ITD—Facemask Only
• Place ResQPOD & ResQPump within first 2
minutes of CPR
• Perform compressions with ResQPump @
80/min (metronome)
•Pause for breaths
•30:2 compression to ventilation ratio
•Compress 65-90 lbs (use gauge) with
active decompression (-20 lbs)
2
Two-Person Rescue Breathing*
*The twohanded
technique is
preferred.
When it’s time to pause compressions to give
breaths, the person doing chest compressions can
reach over and 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 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 8-10
breaths/minute.
2
Troubleshooting, cont'd
Discontinue ResQ POD 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 researchers.
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
Run Follow-up
• Complete patient care record accurately:
— Attempt to record times
—CPR starts/stops
—time of Pump and POD use
—time of intubation, etc.
• Call in to 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…
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.
• 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)
When squeezing the bag, use one
hand and only bring the fingertips
together.
DO NOT increase volume!
back
Rescue Breathing after Intubation
DO NOT pause chest compressions to
deliver breaths after tube placement.
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
Deterioration in knowledge and skills 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 Depth
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
These are CPR Tools
If CPR is in
progress…
When pulse
returns…
back
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.
Cardiac Output
• The two components of cardiac output
that high quality CPR will attempt to
duplicate, ensuring adequate perfusion of
the brain and coronary circulation are:
• Heart rate
• Stroke volume
back
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