Refresher Training: Adult CPR and the ResQ Trial in Whatcom County

1
Refresher TrainingAdult CPR and theResQ Trial
in Whatcom County

• Prepared by
• Janice Lapsansky
• July 2009

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Topics

• Adult CPR

1
ResQ Trial Refresher
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Click on this icon to reveal the
answers to embedded test preview questions
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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
• 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 AHA guidelines.
• Describe the correct performance of active
  compression-decompression (ACD-CPR) with the ResQ
  Pump and ResQ POD, including methods of
  troubleshooting difficulties.
• Describe the information needed to complete the
  hotline report.

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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) a 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

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Adult CPR
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ABCs

• Open the Airway
• Check for Breathing
• Look, listen, and feel
• Check for Circulation

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Opening the Airway
1
head-tilt / chin-lift

• For all victims unless cervical spine injury is
  suspected.

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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 as airway
takes priority.
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Quality CPR
1

• The compression to ventilation ratio is 302
• The ventilation rate during CPR is 1 breath every
  6-8 seconds
• Deliver each rescue breath quickly (1 sec)
• Provide immediate chest compressions

How will you know that your rescue breath is
effective?
The rate of chest compressions with a pair of
hands is
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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.
Are broken bones an expected consequence of CPR?
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AED Defibrillation
1

• 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 right 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
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Defibrillation
1
No stacked shocks
No pulse check after shock
This reduces the no flow time. Why is this
important?

1. single shock
2. 2 minutes of CPR
3. pulse check
4. re-analyze if no pulse

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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.

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

• 302 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

How can I get the best seal using the King
facemask provided in the study packs?
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Rescue Breathing During CPRwith an Advanced
Airway
1

• ET tube, Combi-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?
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Quality of Chest Compressions during Standard CPR
1

• 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 more than
  10 seconds

How will you insure that the heart fills to the
greatest extent possible between chest
compressions?
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Successful CPR
1

• All sites have measured an increase in successful
  resuscitations.
• The improved outcome for our patients could be
  due to
• more frequent CPR training,
• better Standard CPR,
• CPR with the ResQ Pump and ResQ POD, or
• all three of these reasons!
• We do know that rescuers are doing a great job at
• limiting pauses in chest compressions
• managing the airway (facemask seal, rate and
  depth of rescue breaths)
• using the AED

How often should rescuers practice their CPR
skills?
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ResQ Trial Refresher
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ResQ Trial Research Question
2

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

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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?
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Cardiac Pump Component
2

• 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?
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Thoracic Pump Component
2

• 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?
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Decompression Phase
2

• 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)
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Decompression Phase, cont'd
2

• This small but important vacuum (negative
  pressure) developed in the chest
• draws blood back into the chest and heart,
• increases coronary artery blood flow,
• decreases intracranial pressure and increases
  blood flow to the brain during CPR!

Note The ResQ Pump is designed to create this
vacuum more effectively than chest recoil alone
when using a pair of hands.
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Decompression Phase, cont'd
2

• The more blood that returns to the heart
  (preload)
• the more that is pushed forward (cardiac
  output) with the next chest compression.

What are the two components of cardiac output
that CPR should attempt to duplicate?
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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 these CPR Tools
2
Begins creation of the vacuum
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ResQ Pump
2
Force Gauge
Metronome (80 bpm)
Suction Cup
Handle
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Airflow Through the ResQPODduring CPR
2
Compression
Ventiliation
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Airflow Through the ResQPODduring CPR
2
Because the ResQ POD uses a valve to control
airflow, it is also known as
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ResQ Trial Calendar
2

• 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-CPRITD
ACD-CPRITD
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.
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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
• Implement devices within the first 2 minutes of
  CPR
• Do not delay CPR for intubation or AED
• Report any problems during the hotline call

What is a randomization error?
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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
• Lightning/Electricity

If you are uncertain, presume it is
non-traumatic until you discover otherwise.
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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, follow traditional SOPs.
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CPR Success
2

• Follow the correct compression rates
• S-CPR 100/min
• ACD-CPR 80/min
• Allow chest to completely recoil
• Do not hyperventilate!
• Facemask 302 compressions to vents
• Advanced airway 8-10 vents/min
• Rotate compressor every 2 minutes!

If a pulse cannot be restored, how long should
resuscitative efforts last at the scene?
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Standard CPRFacemask Only
2

• Facemask BVM ventilations
• Compress _at_ 100/min
• Pause for breaths
• Compression to ventilation ratio 302

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Standard CPRAdvanced Airway
2

• Airway secured (ET, Combi-tube, or King-tube)
• Continuous compressions _at_ 100/min
• Do not pause for breaths
• Ventilate at 8-10/min (1 breath about every 6-8
  seconds)

King tube
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ACD-CPR Compression
2

• Same depth as in standard CPR
• Compress the chest 1 ½ - 2 (65-90 lbs on strain
  gauge)
• 80 compressions per minute
• Body position is critical to avoid fatigue
• Do not straddle patient

How long should CPR be performed on a patient
with an unwitnessed cardiac arrest before
analyzing with the AED?
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2
ACD-CPR ITD - Facemask Only

• Place ResQ POD ResQ Pump within first 2 minutes
  of CPR
• Perform compressions with ResQ Pump _at_ 80/min
  (metronome)

• Pause for breaths
• 302 compression to ventilation ratio

How do I avoid fatigue and injury while
performing ACD-CPR?
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2
Two-Person CPR
Stretch the cuff on the facemask to improve the
seal. Hold in place by using the fingers of both
hands to bring the jaw to the facemask (rather
than pushing the facemask down onto the face).
When its time to pause compressions to give
breaths, the person doing chest compressions
reaches over to squeeze the ventilation bag.
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2
ACD-CPR ITDAdvanced Airway

• Compress continuously _at_ 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 do I do if the timing lights dont turn on?
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ETCO2 Monitoring
2

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

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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 frequently

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

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Run Follow-up
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.

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Call to the Research Hotline
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.
• Signs of increased LOC during CPR
• 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).

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Cleaning/Reuse
2

• 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
2
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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Finally
Give all victims of cardiac arrest the best
chance of survival Thank you for your teamwork
commitment!
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Written Test
Click here to return to the introduction page and
the link to the written test.
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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
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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
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Risk of Fractures during CPR
1

• 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
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Using the AED

• Apply the AED pads as soon as the patient is
  determined to be without pulse or respirations.
• If the arrest was not witnessed by EMS, analyze
  after 2 minutes (5 cycles) of CPR
• Resume compressions immediately
• Do not pause to check for a pulse after
  delivering a shock.

back
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Appropriate Defibrillation
1
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
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Securing the Airway
Perform chest compressions with a 302
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
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CPR and Rescue Breathing with a Bag-Valve Mask
(BVM)
1
Stretch out the cuff on the King facemask to
improve the seal. Hold in place with 2 hands.
When squeezing the bag, bring the fingertips of
one hand together. DO NOT increase volume!
back
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Rescue Breathing after Intubation
DO NOT pause chest compressions to deliver
breaths after tube placement.
Attempt to time ventilations between chest
compressions during CPR.
back
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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
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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
• Knowledge and skills decrease only 10 weeks after
  completion of training
• Rescuers should practice at least 3 times per year

back
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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
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Chest Compression w/ ResQ Pump
Center the ResQ Pump at the mid-nipple line of
the sternum. Compress the chest using the strain
gauge as a guide 65-90 lbs
back
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1
Blood flow is accomplished beginning with 15
chest compressions, and sustained until
compressions are paused for ventilations.
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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 [phone]

back
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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
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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
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ResQ POD Troubleshooting
3

• The timing assist lights are independent of
• inspiratory impedance function.
• If timing assist lights fail to operate or appear
  to blink at a rate different than ? 10/minute,
  keep POD in place and ventilate the patient at
  10/minute
• approx 101 compression to ventilation ratio
  during S-CPR or 81 during ACD-CPR
• Discontinue use (and replace with 2nd ResQ POD)
  if
• Chest does not rise with ventilation
• Device appears to malfunction in any way

back
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AED

• 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
• Apply the AED pads as soon as the patient is
  determined to be without pulse or respirations.

back
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ACD-CPR Decompression
2

• Lift until force gauge reads approx 20 lbs.

back
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The 2 components of Cardiac Output

• High quality CPR must focus on
• Heart Rate (HR)
• Compress the chest at 100x/min in standard CPR
• Compress the chest with the ResQ Pump at 80x/min
• Stroke volume (SV)
• The heart must fill adequately between
  compressions
• negative pressure created as the chest expands
  returns more blood to the heart, so the next
  chest compression is more effective!
• Adequate HR and SV ensure adequate perfusion of
  the brain and coronary circulation

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The ResQ POD is also known as an Impedence
Threshold Device (ITD).
2
Ventilation Port
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 _at_ -10
cmH2O with spontaneous respiration
Patient Port
back
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Avoid fatigue and injury
Rock your body back and forth, bend at the waist,
keep arms straight
Rotate the compressor every 2 minutes!
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