Refresher Training: The ResQ Trial in Whatcom County

1
Refresher TrainingThe ResQ Trial in Whatcom
County

• Prepared by
• Janice Lapsansky
• January 2008

2
Topics

• Adult CPR

1
ResQ Trial Refresher
2
Click on this icon to reveal the
answers to test preview questions
3
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
• Briefly describe the study objectives and your
  role in the ResQ Trial.
• List the patient inclusion/exclusion criteria.
• State the purpose of the randomization calendar
  and the method your agency uses to insure the
  calendar is followed correctly each week.
• Describe the correct performance of standard CPR
  (with the modified hand position) and use of the
  AED according to current AHA guidelines.
• Describe the correct use of the ResQ POD with
  standard chest compressions during CPR.
• Describe the correct performance of active
  compression-decompression (ACD-CPR) with the ResQ
  Pump and ResQ POD.

4
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

5
Adult CPR
6
ABCs

• Open the airway
• Check for breathing
• Look, listen, and feel
• Check for circulation

7
Opening the Airway
1
head-tilt / chin-lift

• For all victims unless cervical spine injury is
  suspected.

8
Opening the Airway
1
head-tilt / chin-lift

• Without head extension where cervical spine
  injury is suspected.

jaw thrust
If the jaw thrust does not adequately open the
airway use the head-tilt, chin-lift, because
airway takes priority.
9
Quality CPR w/ BVM
1

• The compression to ventilation ratio is 302
• 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
10
Hand Placement
1

• 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?
11
AED Defibrillation
1

• Cardiac arrest not witnessed by EMS
• Perform 5 cycles or 2 minutes of CPR before
  analyzing rhythm

When should the defib pads be applied to the
patient?
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
12
Defibrillation
1
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
13
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.

14
CPR and Rescue Breathing with a Bag-Valve Mask
(BVM)
1

• 302 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?
15
Rescue Breathing During CPRwith an Advanced
Airway
1

• 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?
16
Quality of Chest Compressions
1

• 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?
17
CPR Success
1

• 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?
18
ResQ Trial Overview
19
ResQ Trial Research Question
2

• Is it possible to provide more effective CPR with
  one or both of these tools?

20
ResQ Trial Research Question
2

• 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?
21
Cardiac Pump Component
2

• 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?
22
Thoracic Pump Component
2

• 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?
23
Decompression Phase
2

• 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.

24
Decompression Phase, cont'd
2

• 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

25
Decompression Phase, cont'd
2

• 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

26
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
27
Mechanisms of CPR Tools
2
Begins creation of the vacuum
28
ResQ Trial Calendar
2

• 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.

What is the method used by your agency to insure
that the correct devices are stocked on rescue
vehicles on Sundays at 8am?
29
ResQ Trial Calendar
2

• 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?
30
Inclusion Criteria
2
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.
31
Exclusion Criteria
2
Known or presumed lt 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-CPRITD arm recent sternotomy
(wound not appearing completely healed or, if
known, lt 6 months)
If the patient meets ANY of the exclusion
criteria, perform Standard CPR.
32
Study Protocol3100 patients
2
Cardiac arrest
outcome
33
Study Protocol3100 patients
2
Cardiac arrest
outcome
S-CPR ACD-CPR ITD

• Randomized by week

34
Study Protocol3100 patients
2
Cardiac arrest
outcome
S-CPRACD-CPR ITD

• Randomized by week

• Defibrillation
• Intubation
• IV medications

• Standard
• treatment

35
Study Protocol3100 patients
2
Cardiac arrest
outcome
S-CPR ACD-CPR ITD

• Randomized by week

• Defibrillation
• Intubation
• IV medications

• Standard
• treatment

outcome
36
CPR Success
2

• Follow the correct compression rates
• S-CPR 100/min
• ResQPump 80/min
• Allow chest to completely recoil
• Do not hyperventilate!
• Facemask 302 compressions to vents
• Advanced airway 8-10/min

If a pulse cannot be restored, how long should
resuscitative efforts last at the scene?
37
Run Follow-up
2

• 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).

38
Run Follow-up, continued
2

• ResQPOD place sticker on run report
• Discard used ResQPOD, unless there were problems
• Re-stock with a new ResQPOD from your agencys
  supply.
• (do not restock from the medic rig)
• ResQPump record number on run report
• clean ResQPump and return to service.

39
Standard CPRFacemask Only
2

• Airway not secured (facemask)
• Compress _at_ 100/min
• Pause for breaths
• Compression to ventilation ratio 302

Is this the correct compression rate?
40
Standard CPRAdvanced Airway
2

• Airway secured (ET or Combi-tube)
• Continuous compressions _at_ 100/min
• Do not pause for breaths
• Ventilate at 10/min (once every 10 compressions)

41
2
Two-Person Rescue Breathing with a BVM
Maintain a tight, two-handed facemask seal. When
its time to pause compressions to give breaths,
the person doing chest compressions should reach
over and squeeze the ventilation bag.
42
2
ACD-CPR ITDFacemask Only

• ResQPump study package with facemask, ResQPOD
  sticker
• Place ResQPOD ResQPump within first 2 minutes
  of CPR

• Perform compressions with ResQPump _at_ 80/min
  (metronome)
• Pause for breaths
• Compression to ventilation ratio 302
• Compress to 1.5 - 2 with active decompression
  (use gauge)

When should the ResQPODs lights be used?
43
2
ACD-CPR ITDAdvanced Airway

• 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

What should you do if the patients pulse returns?
44
ETCO2 Monitoring
2

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

45
Troubleshooting
2

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

46
Troubleshooting, cont'd
2
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)

47
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.

48
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.

49
ACD-CPR Compression
2

• 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
• Rotate compressor role every 2 minutes.

How long should CPR be performed on a patient
with an unwitnessed cardiac arrest before
analyzing with the AED?
50
2
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 every 2 minutes

When using the ResQPump, how hard should a
rescuer pull up (decompress the chest)?
51
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.

52
Cleaning/Reuse
2

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

53
Untrained Healthcare Providers
2
Do not leave the ResQPOD or ResQPump in the hands
of healthcare providers who have not been trained
in their use.
54
Finally
Give both CPR methods the greatest opportunity to
work Do the best CPR possible!
55
Written Test
Click here to return to the start of
thispresentation
or Close this window and click the ResQ Trial
exam link on the main course page.
56
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
57
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
58
Fatigue Factor
1

• Change roles every 2 minutes (5 cycles)
• Regardless of whether you feel tired!
• Switch quickly to avoid interruptions in CPR

back
59
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
60
Appropriate Defibrillation
1
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
61
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
62
CPR and Rescue Breathing with a Bag-Valve Mask
(BVM)
1
Deliver each breath over 1 second, with visible
chest rise. DO NOT increase volume!
back
63
Rescue Breathing after Intubation
DO NOT pause chest compressions to deliver
breaths after tube placement.
back
64
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
65
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
66
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
67
Chest Compression Depth
Compress the chest 1 ½ - 2 (65-90 lbs on strain
gauge)
back
68
1
Forward blood flow is accomplished beginning with
15 chest compressions, and sustained until
compressions are paused for ventilations.
no-flow time
back
69
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 [phone]

back
70
Study Protocol
2
Cardiac arrest
EMS performs a minimum of 30 minutes of CPR in
all study arms
outcome
S-CPR ACD-CPR ITD

• Randomized by week
• 1033 patients per group

• Defibrillation
• Intubation
• IV medications

• Standard
• treatment

back
outcome
71
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
72
2
The ResQPOD is a CPR tool
Keep the ResQ POD nearby in case the patient
re-arrests.
back
73
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
74
ACD-CPR Decompression
2

• Lift until force gauge reads approx -20 lbs.

Most common error is failure to actively
decompress chest.
back
75
Compressions at a rate of 100/min.

• YES! This is approximately 100 compressions per
  minute.

back
ORyou can hum the Staying Alive song