ohca - from the field to the hospital: best practicesmainecardiohealth.org/ohca - from the field to...

OHCA - From the Field to the

Hospital: Best Practices

Cardiovascular Care Summit

Matthew Sholl, MD, MPH, FACEP

What We Know About Cardiac

Arrest• Minutes matter!

– Mortality increases 10% with each minute the

heart remains in arrest

• Care must begin immediately!• Care must begin immediately!

– Best survival seen in patients who arrest in

public and have access to early defibrillation

• Cardiac arrest care must be highly sequenced!

– Many steps + must be highly organized

Outline and Objectives

• General Comments

• Evidence Evaluation Process

• Adult BLS Update

• Adult ALS Updates• Adult ALS Updates

• Pediatric BLS Updates

• Pediatric ALS Updates

Why Do Guidelines Exist?

How Does the AHA Build the

Guidelines? • Important to review the AHA’s process

• Subject topics broken down into task forces

– Example – BLS, ALS, Acute Coronary – Example – BLS, ALS, Acute Coronary

Syndrome, Pedi ALS, NALS, Stroke, First Aid,

and Education and Implementation

• At the END of the 2005 update, each task force generated a list of unanswered questions

Evidence Experts

• These questions based on knowledge gaps from the last update

– Questions left unanswered in the literature or

with poor evidence surrounding the topicwith poor evidence surrounding the topic

• The Task Forces assigned each question

to a “Evidence Expert”

– Each question assigned to 2 evidence experts

who independently searched the literature

Review Process

• These evidence experts presented their preliminary findings to the Task Forces

– When discrepancy between the 2 experts,

they were asked to reconcile the disparity they were asked to reconcile the disparity

• All evidence presented to the Task Forces

who in turn created “Task Force Consensus on Science and Treatment

Recommendations”

Consensus on Science

Conference• These Task Force Consensus Statements

presented at a major international conference early in 2010 and vetted at that timetime

• After the conference and vetting process a writing group compiles all the Task Force recommendations, accepted comments and amendments and created an international consensus statement

AHA Process

• The AHA is part of the entire process

• Built their recommendations from the process and the final product of the international conferenceinternational conference

Remember…

• These recommendations represent the best data we have available at this time

• The science of resuscitation medicine is changing rapidly and future updates will changing rapidly and future updates will represent those changes

• Some answers we do not have yet and the AHA tries to offer the best fair and balanced input in those situations

On To the Topics…

• Adult BLS

• Adult ALS

• Pediatric ALS

• Pediatric BLS• Pediatric BLS

• Briefly touch on Post Resuscitation Care

Adult BLSAdult BLS

Adult Basic Life Support

• 2010 AHA Guidelines emphasize the importance of high-quality chest compressions including– A rate of at least 100/min (changed from – A rate of at least 100/min (changed from

approximately 100/min)

– A compression depth of at least 2 inches in adults

– Allowing for complete recoil after each compression

– Minimizing interruptions in chest compressions

– Avoiding excessive ventilations

A Word on Compressions…

• Over the last 2 AHA Updates, we have seen increasing attention directed toward chest compressions

• In 2010, chest compressions gained • In 2010, chest compressions gained enough attention that the trusted EMS A/B/C mantra was changed to C/A/B

– Purpose: To reduce delay in chest

compressions

What Saves Lives in Cardiac

Arrest? • Despite being able to bring many

advanced therapies to the patient suffering cardiac arrest the therapies that save lives are:are:

– Early defibrillation

– Chest compressions

• Medications and advanced airways DO NOT improve survival…

The Most Important Treatment

You Offer…• … is effective chest compressions

• Effective means:– Right rate (at least 100)

– Right depth (2.5 inches or 5 cm)– Right depth (2.5 inches or 5 cm)

– Relax – allow for recoil

– NO interruptions

– Avoid excessive ventilations

• Despite our best ALS capabilities, our BLS skills are what appears to be most important

Rescuer Fatigue

• We probably fatigue while doing chest compressions much sooner than we admit

• Best way to check for fatigue is to look for decreases in End Tidal CO2 while decreases in End Tidal CO2 while monitoring the patient

• AHA currently suggests that, if the personnel are available, to rotate chest compressors every 2 minutes to reduce fatigue

A Word on Ventilations….

What is Wrong With Extra

Ventilations? • Most recent changes attempted to

highlight the importance of uninterrupted chest compressions and limited the positive pressure ventilation rate to 8 – 10 positive pressure ventilation rate to 8 – 10 breaths per minute

• Why focus on minimally interrupted chest compressions and limiting positive pressure ventilation?

Minimizing Positive Pressure

Ventilation• Old Paradigm:

– ABC’s – M2M/BVM/ETT to deliver high flow O2

• New Concepts:– Positive pressure ventilation increases intrathoracic – Positive pressure ventilation increases intrathoracic

pressure

– Increased intrathoracic pressure decreases venous

return

– Resultant decrease in coronary and cerebral blood flow

• SO… AHA has recommended RR of 8 – 12 breaths/minute

But What About the Airway and

breathing? Part 1• Much smaller amounts of ventilation are

needed:

– Immediately after arrest, aortic O2 and CO2

concentrations are similar to the pre-arrest concentrations are similar to the pre-arrest

state

• There exists no blood flow and oxygen

consumption is minimal

But What About the Airway and

breathing? Part 2 – Lungs act as an oxygen reservoir for the

much reduced pulmonary blood flow

• Under BEST practices – pulmonary blood flow

during CPR is 10-15% of pulmonary blood flow

during NSRduring NSR

– Substantial ventilation occurs due to passive

movement during compression and expansion

during CPR

PULSE CHECKS?

Pictures are for presentation purposes only. The American Heart Association does not endorse any particular products, models or manufacturers.

Just In Time Training


Hands Only CPR

Total Number of Compressions:

At Least 100


One Way to Remember This…

Other Songs…

ABBA Dancing Queen

All American Rejects Gives You Hell

Arrested Development Tennessee

Backstreet Boys Quit Playing Games (With My Heart)

Bangles Walk Like An Egyptian

Beastie Boys Body Movin’ [Fatboy Slim Remix]

Beastie Boys Heart Attack Man

Beastie Boys Root Down

Black Crowes Hard To Handle

Linkin Park Breaking the Habit

Ludacris The Potion

Madonna Who’s That Girl

Mariah Carey Heartbreaker

Marvin Gaye What’s Going On

Michael Jackson Man In The Mirror

Missy Elliott Work It

Motley Crue Kickstart My Heart

Notorious B.I.G. Notorious B.I.G. [Featuring Lil’ Kim and Puff Daddy]

Patty Loveless Strong HeartBlack Crowes Hard To Handle

Black Eyed Peas Hey Mama

Bon Jovi Lay Your Hands On Me

Cyndi Lauper Girls Just Want To Have Fun

Diana Ross Ain’t No Mountain High Enough

Fall Out Boy This Ain’t A Scene, It’s An Arms Race

Guns N’ Roses Paradise City

Hanson Mmmbop

John Denver Thank God I’m A Country Boy

Justin Timberlake Rock Your Body

KT Tunstall Suddenly I See

Lily Allen LDN

Patty Loveless Strong Heart

Paul Oakenfold Starry Eyed Surprise

Phil Collins You Can’t Hurry Love

Ricky Martin Shake Your Bon Bon

Rod Stewart You’re In My Heart

Shakira Hips Don’t Lie [Featuring Wyclef Jean]

Simon & Garfunkel Cecilia

Soul II Soul Back To Life

Stray Cats Rock This Town

Sugar Ray Fly

Tracy Chapman Fast Car

U2 I Still Haven’t Found What I’m Looking For

No ROUTINE Cricoid Pressure


CPR or AED First?


AED’s and Infants


Mechanical CPR


Impedance Threshold Device


Piston Device


Load Distributing Band


Teamwork and ICS


Advanced Cardiac Life Support


Major Changes

• Algorithm Changes

• Medication Changes

• Endorsement of Capnography

• Importance of “Systems of Care” and diligent approach to the patient with return of spontaneous circulation (ROSC)

Four Major ALS Algorithms

• Universal Algorithm

• Adult Pulseless Arrest

• Bradycardia

• Tachycardia • Tachycardia

Atropine Removed from the

Pulseless Arrest Algorithm


Adenosine


ALSCapnography


1. Capnography has been used to

prognosticate outcome in cardiac arrest

patients using this principle

– ETCO2 of 10 or less after 20 minutes of ACLS – ETCO2 of 10 or less after 20 minutes of ACLS

successfully discriminated between survivors and

nonsurvivors

2. Capnography helps in the evaluation of CPR

compressions

– Should see increases in ETCO2 with effective CPR

and decreases if effectiveness declines

1. Increases in ETCO2 are also the first indictor in ROSC

– During CPR, sudden increases in ETCO2 are

early indicators of ROSCearly indicators of ROSC

2. In the post-arrest or critical patient, ETCO2 and Capnography may herald loss of circulation

– In the previously stabilized patient, sudden drops

in ETCO2 should prompt the rescuer to

reinitiating CPR

• Capnography is one of the tools helpful in confirming intubation

– Expect to see a normal or near normal

ETCO2 and waveforms within a few breathsETCO2 and waveforms within a few breaths

• More importantly, Capnography is the only tool that allows ongoing live-time evaluation of ETT placement

The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide

monitoring on the rate of unrecognized misplaced intubation within a regional

emergency medical services system.

Ann Emerg Med May 2005

RESULTS:

• Two hundred forty-eight patients received out-of-hospital airway management, of whom 153 received intubation.

– Of the 153 patients, 93 (61%) had continuous ETCO2 monitoring, and 60 (39%) did not.

– Forty-nine (32%) were medical patients, 104 (68%) were trauma patients, and 51 (33%) were in cardiac arrest.

• The overall incidence of unrecognized misplaced intubations was 9%. • The overall incidence of unrecognized misplaced intubations was 9%. – The rate of unrecognized misplaced intubations in the group for whom continuous ETCO2

monitoring was used was zero, and the rate in the group for whom continuous ETCO2 monitoring was not used was 23.3%

CONCLUSION:

• No unrecognized misplaced intubations were found in patients for whom paramedics used continuous ETCO2 monitoring. Failure to use continuous ETCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.

• In cases on normal intubation with sudden loss

of tube placement, the capnogram will appear

normal (when the tube is properly placed) and

will then go flat

• Similar to the patient who becomes apnic

• In cases with little to no CO2 in the stomach, the

ETCO2 will be zero and the capnogram will be

flat or will have very low and irregular amplitude

• There are 2 conditions in which you may transiently see

a capnogram after esophageal intubation and

carbonated beverages in the stomach is one of these

conditions

• Will see bizarre wave form with goes flat within 6 breaths• Will see bizarre wave form with goes flat within 6 breaths

• Occasionally, enough alveolar gas and CO2 can

be forced into the stomach during bagging that

the capnogram will transiently appear normal

• Within 10 breaths, this CO2 washes out and the • Within 10 breaths, this CO2 washes out and the

amplitude decreases, eventually zeroing

Termination of Resuscitation


ohca - from the field to the hospital: best practicesmainecardiohealth.org/ohca - from the field to...

Documents