Refresher Training: The ResQ Trial in Whatcom County

1. Refresher Training:The 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. 1 Adult CPR

6. ABC’s • Open the airway • Check for breathing • Look, listen, and feel • Check for circulation

7. 1 Opening the Airway head-tilt / chin-lift • For all victims unless cervical spine injury is suspected.

8. 1 Opening the Airway 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. 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:

10. 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?

11. 1 AED & Defibrillation 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. 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

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. 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?

15. 1 Rescue Breathing During CPRwith 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?

16. 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?

17. 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?

18. 2 ResQ Trial Overview

19. 2 ResQ Trial Research Question Is it possible to provide more effective CPR with one or both of these tools?

20. 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?

21. 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?

22. 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?

23. 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.

24. 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

25. 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

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. 2 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. = Mechanisms of CPR Tools Begins creation of the vacuum

28. 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. What is the method used by your agency to insure that the correct devices are stocked on rescue vehicles on Sundays at 8am?

29. 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?

30. 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.

31. 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.

32. 2 Study Protocol—3100 patients Cardiac arrest outcome

33. 2 Study Protocol—3100 patients Cardiac arrest outcome S-CPR ACD-CPR + ITD • Randomized by week

34. 2 Study Protocol—3100 patients Cardiac arrest outcome S-CPRACD-CPR + ITD • Randomized by week • Defibrillation • Intubation • IV & medications • Standard • treatment

35. 2 Study Protocol—3100 patients Cardiac arrest outcome S-CPR ACD-CPR + ITD • Randomized by week • Defibrillation • Intubation • IV & medications • Standard • treatment = outcome

36. 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?

37. 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).

38. 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.

39. 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?

40. 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)

41. 2 Two-Person Rescue Breathing with a BVM Maintain a tight, two-handed 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.

42. 2 ACD-CPR + ITD—Facemask Only • ResQPump & study package with facemask, ResQPOD & sticker • Place ResQPOD & ResQPump withinfirst 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?

43. 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?

44. 2 ETCO2 Monitoring Place the ETCO2 sensor between the ventilation source and the ResQPOD.

45. 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 8-10/minute, disregard the lights, continue using the ResQPOD, and ventilate the patient at 10 breaths/minute.

46. 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)

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. 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 • 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)?