Transcript Medic One/Emergency Medical Services

Refresher Training:
The ResQ Trial in
Whatcom County
Prepared by
Janice Lapsansky
January 2008
Topics
1
Adult CPR
2
ResQ Trial Refresher
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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 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