Adult CPR and the ResQ Trial

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Adult CPR and the ResQ Trial
Prepared by Janice Lapsansky Spring 2006
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Agenda

• Major Changes in AHA guidelines for adult CPR
• ResQ Trial overview
• Study objectives
• Patient inclusion/exclusion criteria
• Randomization schedule
• Study protocol
• Manikin practice and skills evaluation
• Standard CPR with modified hand position
• Use of an impedance threshold device (ResQ POD)
• Performance of active compression-decompression
  (ACD-CPR) with the ResQ Pump and ResQ POD
• (Note a new ResQ Trial training video is being
  produced)

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Major Changes in Adult CPR

• Compression to ventilation ratio (302 for all
  levels of rescuers)
• Ventilation rate changes in CPR
• Each rescue breath is delivered more quickly (1
  second)
• Emphasis on immediate chest compressions and
  improved technique
• AED shock cycle changes
• Opening the airway

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Phone First or CPR First?Tailor The Sequence to
Meet the Need

• Lone HCP will Phone First
• On an unresponsive adult, when collapse is most
  likely cardiac in origin.

• Lone HCP will do CPR First
• On a victim of any age, including adult, when the
  cause is likely do to hypoxic (asphyxial) arrest
  (e.g. drowning, drug overdose).
• Do 5 cycles or 2 minutes of CPR, then activate EMS

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
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Opening the Airway

• Open the airway using head tilt, chin lift on
  trauma victims, unless cervical spine injury is
  suspected. Use the jaw thrust without head
  extension for suspected C-spine. If the jaw
  thrust does not adequately open the airway, use
  the head tilt, chin lift as airway takes priority
  for the unresponsive trauma victim.
• Manual stabilization of the C-spine is preferred
  over mechanical devices.

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Rescue BreathingWithout Chest Compressions

• No major changes to rescue breathing, but wider
  range allows rescuer to tailor respiratory support

Adults - 10/12 breaths/min (1 per 5-6 sec)
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
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Rescue Breathing during CPR

• Deliver each breath over 1 second, with visible
  chest rise
• DO NOT increase volume!
• BVM 302 compression to ventilation ratio
• hold tight facemask seal
• count out loud (1 and 2 and 3 and)
• pause after 30 compressions for delivery of two
  rescue breaths when ventilating with BVM
• Advanced Airway ET tube, Combi/EZ tube -
  ventilations should be given 8-10 times per
  minute, or approximately every 6-8 seconds for
  all victims in cardiac arrest (adult, child, and
  infant)
• Do not pause chest compressions to deliver breaths

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Quality of Chest Compressions

• Proper technique when delivering chest
  compressions absolutely critical
• Emphasize push hard, push fast
• Adult compressions must be 1 ½ - 2 inches deep
• Picture the heart being compressed b/w sternum
  and spine
• Rate must be 100/min
• Do not interrupt chest compressions for longer
  than 10 seconds (e.g. to give rescue breaths or
  to analyze rhythm)
• Must allow full chest recoil after each
  compression.

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Fatigue Factor

• Rescuers must change positions after every 2
  minutes, or 5 cycles, of CPR to maintain proper
  quality
• Regardless of whether you feel tired!
• Rescuers should switch quickly to avoid any
  interruptions in CPR quality.

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Hand Placement

• Use the mid-nipple line for adults and children

When using two-hand technique, rock the heel of
the hand off the chest using fingertips on chest
wall to maintain hand position
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Defibrillation

• Elimination of consecutive (stacked) shocks
• Single shock will be followed by 2 minutes of
  CPR, then pulse check, and re-analyze if
  necessary
• Altered protocol for witnessed versus unwitnessed
  arrest
• With EMS-witnessed arrest Use AED first in
  adult victims when AED is immediately available
• If EMS does not witness the arrest, then do 5
  cycles or 2 minutes of CPR, beginning with chest
  compressions.
• Immediate chest compressions of good quality will
  supply blood to the heart muscle that will help
  it respond better to medications and AED shocks!

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Relief of Foreign Body Airway Obstruction

• Terminology change only-
• Delete the 3 categories of partial airway
  obstruction with GOOD air exchange, partial
  airway obstruction with POOR air exchange, and
  complete obstruction to
• Mild airway obstruction
• Severe airway obstruction

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ResQ Trial Research Question

• Is it possible to provide more effective CPR with
  one or both of these CPR tools, as compared to
  standard CPR?
• Patient Survival
• Neurologic health (and quality of life)

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Cardiac Pump Component

• Blood flow during CPR is due to the direct
  compression of the heart between the sternum and
  the spine.

May play particularly important role only during
the early phases of CPR (valves become less
effective after prolonged arrest).
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Thoracic Pump ComponentCompression Phase

• During chest compression, increased pressure in
  the chest, aided by one-way valves in the heart
  and venous system, cause forward movement of
  blood through the circulatory system.

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Decompression Phase

• Ribs sternum act as a bellows.
• Blood returns to the heart during the relaxation
  (decompression) phase.
• A small, but important, vacuum (negative
  pressure) forms in the chest and draws blood back
  into the chest and heart.
• The more blood that returns to the heart
  (preload), the more that is circulated forward
  (cardiac output) with the next chest compression.

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• 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
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Mechanisms of CPR Tools

• Goal Enhance the negative pressure (or vacuum)
  in the chest during the decompression phase of
  CPR in order to return more blood to the heart.
• ResQPump Begins the creation of the vacuum
• ResQPOD Sustains the vacuum that is created,
  either by elastic recoil of chest wall or by
  ResQPump

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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
• Patients will be analyzed according to the
  treatment that they should have received, not
  what they actually got.
• Follow the schedule exactly
• Implement the devices ASAP do not delay!
• Report errors

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Inclusion Criteria

• Adults known or presumed to be 18 yrs
• Presumed non-traumatic cardiac arrest
• 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
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Exclusion Criteria

• Known or presumed lt 18 years
• Obvious or likely traumatic etiology
• Penetrating or blunt trauma
• Pre-existing DNR orders
• Obvious signs of clinical death
• Family members who request exclusion
• For ACD-CPRITD arm recent sternotomy (wound not
  appearing completely healed or, if known, lt 6
  months)

If the patient meets ANY of the exclusion
criteria, follow traditional standard operating
procedures.
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Study Protocol (3100 pts)
ACD-CPR ITD
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Exceptional CPR Quality

• Follow correct compression rates
• S-CPR 100/min
• ACD-CPR 80/min
• Allow chest to completely recoil
• Do not hyperventilate
• Facemask 302 compression to ventilation ratio
• Maintain tight seal at all times do not
  interrupt chest compressions for placement of
  advanced airway
• Advanced airway 8-10/min
• Provide rescue breaths over 1 second that produce
  visible chest rise
• Avoid interruptions of CPR longer than 10 sec.
• Attempt EMS-provided resuscitation for a minimum
  of 30 minutes for ALL STUDY ARMS

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Run Follow-up

• Complete patient care record accurately
• Attempt to record times that CPR starts/stops,
  time of Pump and POD use, time of intubation,
  etc.
• Print code summary
• Call in to research hotline (24/7)
• 1-866-640-2832
• ALL ARRESTS regardless of whether entered and
  regardless of resuscitation attempted
• ResQPOD place sticker on run report
• dispose of ResQPOD unless there were problems
  replace with new
• ResQPump record number on run report
• clean ResQPump and reuse

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Standard CPR (S-CPR)

• Package with facemask only
• Airway not secured (facemask)
• Compression to ventilation ratio 302
• Compress to 1.5 - 2 allow complete recoil with
  modified hand position
• Compress at rate of 100/min but pause for breaths
• Ventilate over 1 second
• Airway secured (ET or Combi-tube)
• Compress continuously _at_ 100/min do not pause for
  breath
• Compress to 1.5 2 allow complete recoil with
  modified hand position
• Ventilate at 8-10/min (1 breath about every 6-8
  seconds)
• Ventilate over 1 second

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Standard CPR ResQPOD

• Package with facemask, ResQPOD, adaptor sticker
• Place ResQPOD on facemask ASAP
• Airway not secured (facemask)
• Compression to ventilation ratio 302
• Compress to 1.5 - 2 allow complete recoil with
  modified hand position
• Compress _at_ 100/min pause for breaths (less than
  10 sec)
• Ventilate over 1 second
• Airway secured (ET tube or Combi-tube)
• Compress continuously _at_ 100/min do not pause for
  breaths
• Compress to 1.5 2 allow complete recoil with
  modified hand position
• Move ResQPOD to airway and turn on timing assist
  lights
• Ventilate according to lights or 8-10
  breaths/min
• Ventilate over 1 second

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Hand placement to maintain a tight seal
Two-person rescue breathing
One person rescue breathing
The two-handed technique is preferred. When its
time to pause compressions to give the breaths,
the person doing chest compressions can reach
over and squeeze the ventilation bag.
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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.
(Disconnect the ResQPOD to deliver meds thru ET
tube, then reconnect and continue ventilations.)
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ACD-CPR ITD

• ResQPump package with facemask, ResQPOD adaptor
  sticker
• Place ResQPOD on facemask ASAP
• Airway not secured (facemask)
• Compression to ventilation ratio 302
• Compress to 1.5 - 2 with active decompression
  (use gauge)
• Use ResQPump compress _at_ 80/min (metronome)
  pause for breaths (less than 10 sec)
• Ventilate over 1 second
• Airway secured (ET 1st choice)
• Compress continuously _at_ 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
• Ventilate over 1 second

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If CPR is in progress
When pulse returns
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ETCO2 Monitoring

• Place the ETCO2 sensor between the ventilation
  source and the ResQPOD.

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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 ? 10/minute,
  disregard the lights, continue using the ResQPOD,
  and ventilate the patient at 8-10 breaths/minute.
• 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)

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TroubleshootingResQPOD 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.
• May replace POD with new one (preferred), or d/c
  completely
• Suctioning of tube (w/o fluid in POD) does not
  require that the POD be discontinued
• If any problems with the ResQPOD, save in a red
  bag and return to researchers

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ResQPump
Metronome
Force Gauge
Suction Cup
Handle
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ACD-CPRCompression

• Same as standard CPR
• 1 ½ - 2

Body position is critical to avoid fatigue. Do
not straddle patient. Rotate compressor role _at_
every 2 minutes.
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ACD-CPRDecompression

• Lift until force gauge reads approx.
• 20 to 30 lbs

Most common error is failure to actively
decompress chest
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Troubleshooting ACD-CPR

• Suction problems in 10-15 of patients
• Reposition, shave, or dry off chest
• Continue use unless distracting
• May interfere with AP patch placement
• Move patches
• Requires 25 more rescuer energy
• Rotate frequently
• Rib fractures
• Check placement and continue
• Hickey or bruising to chest
• Continue
• Discontinue use if device appears to malfunction.

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Cleaning/Reuse

• Clean cup with soap and water.
• May be cleaned with bleach solution or other
  disinfectant.
• Check gauge for proper calibration.

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Untrained Healthcare Providers

• Do not leave the ResQPOD or ResQPump in the hands
  of healthcare providers who have not been trained
  in their use.

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Q
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