high functioning cpr bringing science to the pit crew final 3-1-13

8/13/2019 High Functioning CPR Bringing Science to the Pit Crew FINAL 3-1-13

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Bringing Science to the Pit Crew:

High-Functioning EMS CPR Teams


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The Science


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Time

%Surviv

ing

arrest

CPR

defibrillation

ROSC

hospital

discharge

Cardiac arrest is the ultimate EMS disease!


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1961

A. Peter Safar, 1950s

B. Early symposium on CPR

A B

CPR is over 50 years old, but recent

changes have shown increases in survival


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Could

Not

Resuscitate

Resuscitated

But

Expired

24-hour

Survivors

35

30

2520

15

10

5

0C

oronaryPerfusion

P

ressure(mmH

g)

Kern, Ewy, Voorhees, Babbs, Tacker Resuscitation1988; 16: 241-250

Not the pH

Not the oxygen content

Survival is related to arterial pressures

generated by chest compressions

Its all about oronaryPerfusion Pressure

Paradis et al.JAMA 1990; 263:1106


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10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 R>120

Chest compression rate (min-1)

Numberof30s

ecsegments

300

250

200

150

100

50

0

n=1626 segments

Chest compression rates

Abella et al, 2005


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No ROSC

ROSC

10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 >120

Chest compression rate (min-1)

Mean rate, ROSC group

90 17 *

Mean rate,no ROSC group

79 18 *

210

180

150

120

90

60

30

0

Nu

mberof30secsegments

Survival better with compression rate of

100120 compressions/minute

Abella et al, 2005

p=0.003


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40

32

24

16

8

0

1 2 3

CPR duration, min

CPP,mmH

g

ICCM, 2005

2 inches vs 1.5 inches Survival:

100%

15%

Survival better with compressions >2 inches deep


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Shocksuccess,percent

Compression depth, inches

n=10 n=5n=14n=13

p=0.02

Shock success by compression depth

Edelson et al, 2006


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2005 AHA Guidelines


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2010 AHA Guidelines

EVENEVEN

EVEN


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How Does CPR Cause Blood Flow?Thoracic Pump

+


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Ensure Total Chest Recoil with:1) Lifting palm during compressions

or2) Using feedback device

+


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Allow Complete Recoil


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Allow Complete Recoil

Lift Palms During Compressions


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CPR sensing and recording defibrillator

Examples: Devices providing real-time feedbackare available from several manufacturers


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Aufderheide et al, 2004

mean ventilation rate: 30 3.2

first group: 37 4 after retraining: 22 3

16 seconds

v v v v v v v v v v

Patients can be hyperventilated to DEATH!


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5 sec

80

160

mmHg

Time (sec)

40

120

0

CoronaryPerfusion Pressures

Cerebral PerfusionPressures No CerebralPerfusion

Single rescuer performing 30:2 with realistic 16 sec.

interruption of chest compressions for MTM ventilations

EwyGA, Zuercher, M. Hilwig, R.W. et al Circulat ion2007;116:2525


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0

5 sec

80

160

mmHg

Time (sec)

40

120

CoronaryPerfusion Pressures

Continuous Cerebral Perfusion Pressures

Single rescuer performingcontinuous chest compressions

Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulat ion2007;116:2525

Perfusion with continuouscompressions


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Influence of cardiopulmonary resuscitation priorto defibrillation in patients with out-of-hospitalventricular fibrillation

Defib first CPR (90 sec) first, then defib42 months 36 months

24% (155/639) 30% (142/478) p=0.04

Cobb et al, 1999

CPR before defibrillation may increasesurvival (when CA not witnessed by EMS)


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0 2 4 6 8 10 12 14

0.5

0.4

0.3

0.2

0.1

0

Wik et al, 2003

CPR firstStandard care

probabilityofsurvival

time from collapse, min

CPR first may improve survival: RCT

p=0.006


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Pause before shock

4:55 5:00 5:05 5:10

Compressions

ECG

Chest compression pauses before shocks


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0

20

40

60

80

100

10.3(n=10)

10.5-13.9(n=11)

14.4-30.4(n=11)

33.2(n=10)

Pre-shock pause, seconds

Sh

ocksuccess,perce

nt

90%

10%

55%

64%

p=0.003

Shock success by pre-shock pauses

Edelson et al, 2006


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CPR renaissance: measuring CPR matters

Valenzuela et al, Circ 2005

Wik et al, JAMA 2005

Abella et al, JAMA 2005

Aufd erheide et al,Circ 2004


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Key take home points

1.Cardiac arrest is not hopeless!

2.CPR quality has biggest impact Adequate chest compression rate (100-120/min) Maximize chest compression depth (>2 in.) Allow for complete chest recoil Minimize pauses !!

3.Minimize ventilations (8-10 bpm)

4.Use capnography & debriefing,consider CPR feedback tools

5.Ensure access to hypothermia

and cardiac catheterization


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The Metabolic Phase (~>10 minutes)

Survival decreased

Science searching for more successful treatments

3-Phase Time-Sensitive Model ofCardiac Arrest Due to VF

The Electrical Phase (0 to ~5 minutes)

Early defibrillation life-saving

The Circulatory Phase (~5 to ~10 minutes)

Intubation and immediate AED can be detrimental

Compressions first may be life saving

Weisfeldt ML, Becker LB. JAMA2002;288:3035


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Bystander contacted 9-1-1

standard CPR (n=960) chest compression alone (n=981)

Dispatcher-assisted hands-only CPR

2010

Survival to DC

11.5% 14.4% (OR 2.9)


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CPR (2010) emphasizes:

Circulation

Airway

Breathing

CCR (Cardiocerebral Resuscitation)

emphasizes:

Circulation (uninterrupted compressions)Deemphasizes ventilation


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Tucson version (2003) Cardiocerebral Resuscitation(Intubation delayed; Bag Valve Mask ventilation)

200 chestcompressions


No intubation:

Bag Valve Mask

ventilation

Analys

is


Analys

is

Follow ACLS

Guidelines?


EMSarrival

BeginIV

1 mg EPINEPHrine every

3 to 5 minutes

If adequate bystander chest compressions are provided,

EMS providers perform immediate rhythm analysis and shock

if indicated

Analys

is


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35%30%25%20%15%10%

5%0%

17.7%

33.7%

SvvaoHoptaishg

Std-CPR COCPR

Survival after Bystander CPR for OHCA in Arizona (2005 to 2010)

Compression Only CPR Advocated and Taught

Bobrow, et al. JAMA 2010:304:1447-1454

P < 0.001

Witnessed/Shockable

7.8%

Std-CPR13.3%

COCPR

A. B.All OHCA

AOR 1.6 (95% CI, 1.08-2.35)


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Neurological Intact Survival from CCRWitnessed collapse and shockable rhythm

NeurologicallyNormal

SurvivaltoHospita

lDischarge 50%

40%

30%

20%

10%

0%

75/192

K.C. MO

34/136

ArizonaRock and Walworth

38%38%39%

35/89 39/102

Annals Emergency

Med2008 Circulation2009Annals Emergency

Med2009


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Gasping Should Not Distract fromRecognizing Patient in Cardiac Arrest

EMD recordings of 445 witnessed cardiac

arrests

Non-witnessed arrest: 16% gasping

Witnessed arrest: 55% gasping

(p


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Medications proven to improve

outcome in cardiac arrest?


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The priority is quality compressions

2009

Reflected in the poor impact of ACLS meds:

Randomized trial of EPINEPHrine versus no EPINEPHrineFor EMS treated cardiac arrest NO BENEFIT IN

SURVIVAL TO DISCHARGE FROM HOSPITAL!
http://www.google.com/imgres?imgurl=http://www.goodmoney.com/norflag.gif&imgrefurl=http://www.goodmoney.com/norway.htm&h=288&w=475&sz=4&tbnid=MXESPrIWofUxrM:&tbnh=78&tbnw=129&prev=/images?q=norway+flag&hl=en&usg=__N13G4IS7k1SvgCqXnFjG_7iVgUc=&sa=X&ei=0m5hTIKQFoOClAfG2-H9CQ&ved=0CCkQ9QEwAw


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The Pit Crew Approach

AHA 2010


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AHA 2010Guidelines

C-A-B Uninterupted

chest

compressions Waveform

capnography

Deemphasized: Intubation

Drugs

Mechanical CPR


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Statewide Protocols 331A/ 3031A

General Cardiac Arrest - Adult

Dont be fooledby agonal

respirations

Cycles of 200

uninterruptedcompressions

Early defib if

good bystanderCPR or EMS

witnessed arrest


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331A

4 cycles of 200

compressions/

defib

Compressions

cause passiveventilation

Medical

director sets

airway/ventilation

options


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331A

After 4 cycles of 200 uninterrupted

compressions, add ventilations at 15:1

Indications for possible BLS field termination of CPR Arrest not witnessed by EMS, AND

No ROSC/pulse prior to transport, AND

No AED shock delivered prior to transport


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3031A EPINEPHrine every 3-5

minutes

Antidysrhythmic if 2nd

shock needed

Medical director setsairway/ventilation

options for agency

Monitor capnography

Avoid intubation during

initial cycles of

compressions


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3031A


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3031A

Treat reversible causes

Pneumothorax

Hypovolemia

Appropriate medication

Antidysrhythmic

Mg for torsades (rare)

Calcium/bicarbonate in

dialysis

Avoid inappropriate care

Naloxone

Glucose testing

Hi h F ti i CPR A


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High-Functioning CPR AgencyThe Pit Crew Team


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Equipment organized to be efficient


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Team member roles pre-assigned


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Frequent practice/ simulation

L E i NASCAR Pi C
http://www.youtube.com/watch?v=nQQbEfr9irEhttp://www.youtube.com/watch?v=nQQbEfr9irE


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Lets Examine a NASCAR Pit Crew

T L d Att ib t
http://www.youtube.com/watch?v=nQQbEfr9irEhttp://www.youtube.com/watch?v=nQQbEfr9irE


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Team Leader Attributes

NREMT

1. Creates, implements and revises an action plan

2. Communicates accurately and concisely while listening andencouraging feedback

3. Receives, processes, verifies, and prioritizes information

4. Reconciles incongruent information

5. Demonstrates confidence, compassion, maturity, (respectfor team members), and command presence

6. Takes charge

7. Maintains accountability for teams actions/outcomes

8. Assesses situation and resources and modifies accordingly

T M b Att ib t


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Team Member Attributes

NREMT

1. Demonstrates followershipis receptive toleadership

2. Maintains situational awareness

3. Utilizes appreciative inquiry4. Avoids freelance activity

5. Uses closed-loop communication

6. Reports progress on tasks

7. Performs tasks accurately and in a timely manner8. Advocates for safety and is safety conscious at alltimes

9. Leaves ego/rank at the door

Pit Crew Approach


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Pit Crew ApproachCompressions are Priority

Continuous chest compressions with minimal interruptionare key

USE any available feedback device/ metronome

Alternate compressions between providers across

patients chest (e.g. 100 each) Chest compressions should continue when charging an

AED or manual defibrillator

Chest compressions should resume immediately after any

shock

Goal = keep interruptions for rhythm check/defibrillation < 10

seconds

Goal = NO interruption for airway device insertion


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Pit Crew Approach

The Triangle of Life


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Pit Crew Approach


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Pit Crew ApproachAirway Options During CPR

Airway insertion must not

interrupt compressions !

Intubation deemphasized and

should be delayed until after

800 compressions

Options with 3031A (set by

medical director): Naso/oropharyngeal Airway +

NRB oxygen

King LT/ Combitube + oxygen

Pit Crew Approach


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Pit Crew ApproachVentilation Options During CPR

Avoid Hyperventilation!

Options with 3031A (set by medical

director):

No ventilation during initial 800compressions(with open airway, there is

passive ventilation with compressions)

1 ventilation/ 15 compressions

Monitor ventilation by capnographyITD optional

Pit Crew Approach


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Pit Crew ApproachBreathing / Ventilation Summary

Ventilation not needed during initial 4

cycles of CPR for PRIMARY CARDIAC

ARREST

Ventilation still has role in:

Pediatrics,


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Pit Crew ApproachBreathing / Ventilation Summary

If BVM used,

2-Person, 2-Thumbs-up

Technique Preferred

Pit Crew Approach
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Pit Crew ApproachMedications During CPR

Routes

? IO first line access

ETT ineffective

No role for checking labs

Role of medications

Epinephrine (IIb)

Ideally within first minute

Antidysrhythmic (IIb)

For refractory VF/VT

Pit Crew Approach


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Pit Crew ApproachMechanical CPR Devices

Mechanical CPR devices do not lead to moresurvivors than manual CPR

Minimizing interruption in chest compressions

during first 10 minutes of cardiac arrest is

critical, so mechanical CPR device by BLSproviders must be delayed until after the

first 4 cycles of uninterrupted

compressions/defibrillation attempts


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Real-time feedback examples

Pit Crew Approach


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Pit Crew ApproachHow can we monitor our success?

Real-time feedback

Feedback from monitor/AED

Continuous waveform capnography Post-code

Debriefing

QI Review Benchmarking (Cardiac Arrest Registry for

Enhanced SurvivalCARES)

Pit Crew Approach


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Pit Crew ApproachHigh-functioning Team

Teamwork Leadership

Situational Awareness (Roles)

Communication

Mutual Support

Role of Checklist

Designed for Efficiency/ Uniformity

Evidence-based

Perfect practice makes perfect

Initial training/ Simulation

Regular practice/ Simulation

High-Functioning CPR Team


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High-Functioning CPR TeamContinuous Quality Improvement

Each agency must adjust pit crew

example diagram for local response:

Number of responders

BLS and ALS Device preferences

Medical director oversight

Must Measure Outcomes

PDSA Cycle (Continuous Improvement)

PlanDoStudyAct

Small Tests of Change

Sequential improvement in Wake


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Sequential improvement in Wake

County, NC

3080 Post resuscitation Care
http://www.wakeems.com/saem


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3080Post-resuscitation Care

Checklist

Before moving patient:

Augment marginal BP with IV fluid bolus and pressor drip

Obtain 12-lead ECG if possible

Titrate O2 to SpO2 between 9599%

Monitor continous ETCO2 and ventilation rate if advanced

airway

Mask travels with bag-valve no matter what airway is in place

Package on backboard/firm surface

Is transport to center capable of PCI / hypothermia possible?

Conclusion


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Conclusion

Improved Dispatch/Bystander CPR

High-quality uninterrupted compressions

NASCAR Pit Crew Approach to Cardiac Arrest

Transport to hypothermia/PPCI Center

QIMeasure Our Outcomes

Celebrate Our Success !!


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Thank You!

Dr. Gordon Ewy (Univ. of Arizona)Dr. Benjamin Abella (Univ. of Pennsylvania)

for providing several slides to this presentation

high functioning cpr bringing science to the pit crew final 3-1-13

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