Adult CPR and theResQ Trial in

Whatcom County

Prepared byJanice Lapsansky

January 2009

Topics

Adult CPR1

2 ResQ Trial Overview

Click on this icon to reveal the answers to embedded test preview

questions

Click on this icon to reveal the answers to embedded test preview

questions

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:

1. Briefly describe the study objectives and your role in the ResQ Trial.

2. List the patient inclusion/exclusion criteria.3. State the purpose of the randomization calendar and the

method your agency uses to insure the calendar is followed correctly each week.

4. Describe the correct performance of standard CPR (with the modified hand position) and use of the AED according to the recent AHA guidelines.

5. Describe the correct use of the ResQ POD with standard chest compressions during CPR.

6. Describe the correct performance of active compression-decompression (ACD-CPR) with the ResQ Pump and ResQ POD.

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) – 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

Adult CPR1

ABC’s

• Open the Airway• Check for Breathing

• Look, listen, and feel

• Check for Circulation

Opening the Airway1

head-tilt / chin-lift

head-tilt / chin-lift

• For all victims unless cervical spine injury is suspected.

Opening the Airway1

• Without head extension where cervical spine injury is suspected.

head-tilt / chin-lift

head-tilt / chin-lift

jaw thrustjaw thrust

If the jaw thrust does not adequately open the airway use the head-tilt, chin-lift as airway takes priority.

If the jaw thrust does not adequately open the airway use the head-tilt, chin-lift as airway takes priority.

Quality CPR

• The compression to ventilation ratio is 30:2• The ventilation rate during CPR is 1 breath

every 6-8 seconds

• Deliver each rescue breath quickly (1 sec)

• Provide immediate chest compressions

1

The rate of chest compressions with a pair of hands is …

How will you know that your rescue breath is effective?

• Use the mid-nipple line for adults and children

1

Hand Placement

Are broken bones an expected consequence of CPR?

Rock the heel of the hand off the chest, keeping fingertips on chest

wall to maintain hand position.

Rock the heel of the hand off the chest, keeping fingertips on chest

wall to maintain hand position.

AED & Defibrillation

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

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 after I deliver a shock?

1

No stacked shocks

No pulse check after shock

Single shock will be followed by 2 minutes of CPR, then pulse check, and re-analyze if necessary

Defibrillation

These measures reduce “no flow time”. Why is it important to reduce the amount of time when compressions are not performed?

Defibrillation

• EMS-witnessed Arrest: —Use AED first in adult victims when AED

is immediately available.

• Unwitnessed Arrest: — 5 cycles or 2 minutes of CPR, beginning

with chest compressions.

Is there a “rule of thumb” about when to intubate the patient?

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

1

• 30:2 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

Because each rescue breath is given quickly, over 1 second, how do you avoid giving too large a volume?

Rescue Breathing During CPRwith an Advanced Airway

1

• ET 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?

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 longer than 10 seconds

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

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 (rate and depth)

• Use defibrillation appropriately

1

How often should rescuers practice their CPR skills?

ResQ Trial Overview2

ResQ Trial Research Question

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

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

2

What does AHA say is the most important factor in overall patient outcome following cardiac arrest?

• 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.

2

Cardiac Pump Component

How far should the chest be compressed when using the ResQ Pump?

• One-way valves in the heart and veins cause forward movement of blood through the circulatory system when pressure increases in the chest.

2

“Thoracic Pump” Component

Approximately how many compressions does it take to move blood from the heart to the brain during CPR?

Decompression Phase2

• 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…)

Decompression Phase, cont'd2

• This small but important vacuum (negative pressure) developed in the chest• draws blood back

into the chest and heart

• increases coronary artery blood flow

Decompression Phase, cont'd2

• The more blood that returns to the heart (preload)…

…the more that is circulated forward (cardiac output) with the next chest compression.

What are the two components of cardiac output that CPR should attempt to duplicate?

“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

Mechanisms of CPR Tools2

Begins creation of the vacuum

Begins creation of the vacuum

Sustains vacuum that is created

Sustains vacuum that is created

=Enhance the negative pressure in the chest during the decompression phase of CPR in order to return more blood to the heart.

ResQ Pump

Metronome(80 bpm)

Force Gauge

Handle

Suction Cup

2

Airflow Through the ResQPOD2

Compression Ventiliation

Airflow Through the ResQPOD

2

Because the ResQ POD uses a valve to control airflow, it is also known as …

ResQ Trial Calendar

• 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.

2

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.

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.

S-CPR

ACD-CPR+ITD

ACD-CPR+ITD

S-CPR

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— Implement devices within the first 2

minutes of CPR— Do not delay for intubation or other

procedures

— Report any problems during the hotline call

2

What is a randomization error?

Inclusion Criteria

*If you are uncertain, presume it is non-traumatic until you discover otherwise.

2

• Cardiac etiology• Respiratory etiology• Stroke• Overdose• Smoke inhalation

Adults known or presumed to be ≥ 18 yrsPresumed non-traumatic* cardiac arrest, such as:

• Drowning• Burns• Metabolic imbalance• Seizures

Exclusion Criteria

If the patient meets ANY of the exclusion criteria, follow traditional SOPs.

2

Known or presumed < 18 yearsObvious or likely traumatic etiology

Penetrating or blunt trauma

Pre-existing DNR ordersObvious signs of clinical death (DOA)Family members who request exclusionFor ACD-CPR+ITD arm: recent sternotomy (wound not appearing completely healed or, if known, < 6 months)

• Follow the correct compression rates:— S-CPR: 100/min— ACD-CPR: 80/min

• Allow chest to completely recoil• Do not hyperventilate!• Facemask: 30:2 compressions to

vents• Advanced airway: 8-10 vents/min

2

CPR Success

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

Standard CPR—Facemask Only2

• Facemask BVM ventilations— Compress @ 100/min — Pause for breaths — Compression to ventilation ratio 30:2

Standard CPR—Advanced Airway

2

• Airway secured (ET or King-tube)— Continuous compressions @ 100/min— Do not pause for breaths— Ventilate at 8-10/min (1 breath about

every 6-8 seconds)

King tubeKing tube

ACD-CPR Compression

• Same objective as in standard CPR

• 80 compressions/minute

• Body position is critical to avoid fatigue

• Do not straddle patient• Rotate compressor role

every 2 minutes.

2

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

•Pause for breaths

•30:2 compression to ventilation ratio

•Compress 65-90 lbs (use gauge) Compress 65-90 lbs (use gauge) with active decompression (-20 with active decompression (-20 lbs)lbs)

2ACD-CPR + ITD—Facemask

Only• Place ResQPOD & ResQPump within first 2

minutes of CPR• Perform compressions with ResQPump @

80/min (metronome)

2

Two-Person Rescue Breathing*

When it’s time to pause compressions to give breaths, the person doing chest compressions can reach over and squeeze the ventilation bag.

*The two-handed technique is preferred.

2ACD-CPR + ITD—Advanced

AirwayCompress continuously @

80/min (metronome)Do not pause for breathsCompress 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 should you do if the patient’s pulse returns?

ETCO2 Monitoring

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

2

Troubleshooting2

• 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 8-10 breaths/minute.

Troubleshooting, cont'd2

Discontinue ResQ Discontinue ResQ POD if:POD 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)

• 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.

2

ResQPOD Fills With Fluid

• 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 researchers.

2ResQPOD Fills With Fluid,

cont'd

2

• 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

Troubleshooting ACD-CPR

When using the ResQPump, how hard should a

rescuer pull up (decompress the chest)?

2

• Rib fractures— Check placement and continue

• Hickey or bruising to chest— Continue

• Discontinue use if device appears to malfunction.

Troubleshooting ACD-CPR, cont'd

Run Follow-up

• 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.

2

Run Follow-up

• Complete patient care record accurately:— Attempt to record times

—CPR starts/stops—time of Pump and POD use—time of intubation, etc.

• Call in to 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).

2

Cleaning/Reuse

• Clean cup with soap and water.

• May be cleaned with bleach solution or other disinfectant.

• Check gauge for proper calibration.

2

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.

Do not leave the ResQPOD or ResQPump in the hands of

healthcare providers who have not been trained in their use.

Finally…

Give all victims of cardiac arrest the best chance of survival…Your teamwork & commitment!

Written Test2

Click here to return to the introduction page and the link to the written test.

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

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

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.

Risk of Fractures during CPR

• 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.

1

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Resuscitation 2004, vol. 63, no3, pp. 327-338

Using the AED

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

• Analyze after 2 minutes (5 cycles) of CPR

• Resume compressions immediately• Do notDo not pause to check for a pulse pause to check for a pulse

after delivering a shock.after delivering a shock.back

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

Appropriate Defibrillation

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Securing the Airway

Perform chest compressions with a 30:2 compression to ventilation ratio for

2 minutes first!

Perform chest compressions with a 30:2 compression to ventilation ratio for

2 minutes first!

back

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.

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

1

When squeezing the bag, use one hand and only bring the

fingertips together.DO NOT increase volume!

When squeezing the bag, use one hand and only bring the

fingertips together.DO NOT increase volume!

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Rescue Breathing after Intubation

DO NOT pause chest compressions to deliver breaths after tube placement.DO NOT pause chest compressions to deliver breaths after tube placement.

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Decompression Phase

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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.

Practice your CPR skills frequently

Good CPR takes training Good CPR takes training ANDAND practice practice Students continue to show Students continue to show

improvement in both knowledge and improvement in both knowledge and skills after 4 training sessionsskills after 4 training sessions

Deterioration in knowledge and skills Deterioration in knowledge and skills only 10 weeks after completion of only 10 weeks after completion of trainingtraining

Rescuers should Rescuers should practicepractice at least 3 at least 3 times per yeartimes per year

Good CPR takes training Good CPR takes training ANDAND practice practice Students continue to show Students continue to show

improvement in both knowledge and improvement in both knowledge and skills after 4 training sessionsskills after 4 training sessions

Deterioration in knowledge and skills Deterioration in knowledge and skills only 10 weeks after completion of only 10 weeks after completion of trainingtraining

Rescuers should Rescuers should practicepractice at least 3 at least 3 times per yeartimes per year

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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

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 Depth

Compress the chest using the strain gauge as a guide:

65-90 lbs

Compress the chest using the strain gauge as a guide:

65-90 lbs

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Blood Flow to Vital Organs During Chest Compressions

Compressions

Perfusion Perfusion Needed

0 5 10 15 20 25 30 0 0 0 0 5

Interruption in chest

compressions

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: 1-866-640-2832 back

Study Protocol

Cardiac arrest

Cardiac arrest

S-CPRACD-CPR + ITD

S-CPRACD-CPR + ITD

– Defibrillation– Intubation– IV &

medications

– Defibrillation– Intubation– IV &

medications

=

outcome

outcomeoutcome

2

• Standard treatment

• Randomized by week• 1033 patients per group

EMS performs a EMS performs a minimum of 30 minimum of 30

minutes of CPR in all minutes of CPR in all study armsstudy arms

EMS performs a EMS performs a minimum of 30 minimum of 30

minutes of CPR in all minutes of CPR in all study armsstudy arms

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The timing-assist lights should be turned on to guide ventilation rate (or 8-10 breaths/min.) only after an advanced airway is placed.

2

ResQPOD with an ET Tube

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If CPR is in progress…

When pulse

returns…

These are CPR Tools3

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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

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ACD-CPR Decompression

Lift until force gauge reads approx: 20 lbs.

Most common error is failure to actively decompress chest.

2

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Cardiac Output

• The two components of cardiac output that high quality CPR will attempt to duplicate, ensuring adequate perfusion of the brain and coronary circulation are:

• Heart rate

• Stroke volume back

Ventilation Port

Patient Port

Safety Check ValveEnables inspiration

@ -10 cmH2O with spontaneous respiration

Atmospheric Pressure

Sensor SystemProvides selective

impedance to inspiratory air flow

Timing Assist Lights ON/OFF

SwitchTurns timing assist

lights on & off

The ResQ POD is also known as an Impedence Threshold Device

(ITD).

2 Timing Assist Lights

Flash @ 10/minPromote proper

ventilation & compression rate

2

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