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Bringing Science to the Pit Crew: High-Functioning EMS CPR Teams

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Title: Bringing Science to the Pit Crew: High-Functioning EMS CPR Teams


1
Bringing Science to the Pit CrewHigh-Functioning
EMS CPR Teams
2
Bringing Science to the Pit CrewHigh-Functioning
EMS CPR Teams
  • The Science

3
Cardiac arrest is the ultimate EMS disease!
arrest
CPR defibrillation
Surviving
ROSC
hospital discharge
Time
4
CPR is over 50 years old, but recent changes have
shown increases in survival
A
B
A. Peter Safar, 1950s B. Early symposium on CPR
1961
5
Survival is related to arterial pressures
generated by chest compressions
35 30 25 20 15 10 5 0
Not the pH
Not the oxygen content
Its all about Coronary Perfusion Pressure !
Coronary Perfusion Pressure (mm Hg)
24-hour Survivors
Could Not Resuscitate
Resuscitated But Expired
Kern, Ewy, Voorhees, Babbs, Tacker Resuscitation
1988 16 241-250
Paradis et al. JAMA 1990 2631106
6
Chest compression rates
300 250 200 150 100 50 0
n1626 segments
Number of 30 sec segments
10-20 20-30 30-40 40-50 50-60 60-70
70-80 80-90 90-100 100-110 110-120 Rgt120
Chest compression rate (min-1)
Abella et al, 2005
7
Survival better with compression rate of 100
120 compressions/minute
Mean rate, ROSC group 90 17
210 180 150 120 90 60 30
0
p0.003
Mean rate, no ROSC group 79 18
No ROSC
ROSC
Number of 30 sec segments
10-20 20-30 30-40 40-50 50-60
60-70 70-80 80-90 90-100 100-110
110-120 gt120
Chest compression rate (min-1)
Abella et al, 2005
8
Survival better with compressions gt2 inches deep
40 32 24 16 8 0
2 inches vs 1.5 inches
Survival 100 15
CPP, mm Hg
1 2 3 CPR duration, min
ICCM, 2005
9
Shock success by compression depth
p0.02
Shock success, percent
n5
n14
n13
n10
Compression depth, inches
Edelson et al, 2006
10
2005 AHA Guidelines
11
2010 AHA Guidelines
EVEN EVEN EVEN
12
How Does CPR Cause Blood Flow?Thoracic Pump

13
Ensure Total Chest Recoil with1) Lifting palm
during compressionsor2) Using feedback device

14
Allow Complete Recoil
15
Allow Complete RecoilLift Palms During
Compressions
16
CPR sensing and recording defibrillator
Examples Devices providing real-time
feedback are available from several manufacturers
17
Patients can be hyperventilated to DEATH!
16 seconds
v v v v v v v v
v v
mean ventilation rate 30 3.2
first group 37 4 after
retraining 22 3
Aufderheide et al, 2004
18
Single rescuer performing 302 with realistic 16
sec. interruption of chest compressions for MTM
ventilations
Cerebral Perfusion Pressures
No Cerebral Perfusion
Coronary Perfusion Pressures
0
Ewy GA, Zuercher, M. Hilwig, R.W. et al
Circulation 20071162525
19
Perfusion with continuous compressions
Single rescuer performing continuous chest
compressions
Continuous Cerebral Perfusion Pressures
Coronary Perfusion Pressures
0
Ewy GA, Zuercher, M. Hilwig, R.W. et al
Circulation 20071162525
20
CPR before defibrillation may increase survival
(when CA not witnessed by EMS)
Influence of cardiopulmonary resuscitation prior
to defibrillation in patients with
out-of-hospital ventricular fibrillation
24 (155/639)
30 (142/478) p0.04
Cobb et al, 1999
21
CPR first may improve survival RCT
0.5 0.4 0.3 0.2 0.1 0
CPR first Standard care
probability of survival
p0.006
0 2 4 6 8 10 12
14
time from collapse, min
Wik et al, 2003
22
Chest compression pauses before shocks
455 500
505 510
Compressions ECG
Pause before shock
23
Shock success by pre-shock pauses
100
p0.003
90
80
60
64
Shock success, percent
55
40
20
10
0
10.3 (n10)
10.5-13.9 (n11)
14.4-30.4 (n11)
33.2 (n10)
Pre-shock pause, seconds
Edelson et al, 2006
24
CPR renaissance measuring CPR matters
Valenzuela et al, Circ 2005 Wik et al, JAMA
2005 Abella et al, JAMA 2005
Aufderheide et al,Circ 2004
25
Key take home points
  • Cardiac arrest is not hopeless!
  • CPR quality has biggest impact
  • Adequate chest compression rate (100-120/min)
  • Maximize chest compression depth (gt2 in.)
  • Allow for complete chest recoil
  • Minimize pauses !!
  • Minimize ventilations (8-10 bpm)
  • Use capnography debriefing,
    consider CPR feedback tools
  • Ensure access to hypothermia
    and cardiac catheterization

26
3-Phase Time-Sensitive Model of Cardiac Arrest
Due to VF
The Electrical Phase (0 to 5 minutes) Early
defibrillation life-saving
The Circulatory Phase (5 to 10
minutes) Intubation and immediate AED can be
detrimental Compressions first may be life saving
The Metabolic Phase (gt10 minutes) Survival
decreased Science searching for more successful
treatments
Weisfeldt ML, Becker LB. JAMA 20022883035
27
Dispatcher-assisted hands-only CPR
2010
Bystander contacted 9-1-1
standard CPR (n960) chest compression
alone (n981)
11.5 14.4 (OR 2.9)
Survival to DC
28
  • CPR (2010) emphasizes
  • Circulation
  • Airway
  • Breathing
  • CCR (Cardiocerebral Resuscitation) emphasizes
  • Circulation (uninterrupted compressions)
  • Deemphasizes ventilation

29
Tucson version (2003) Cardiocerebral
Resuscitation (Intubation delayed Bag Valve Mask
ventilation)
200 chest compressions
200 chest compressions
200 chest compressions
200 chest compressions
EMS arrival
Analysis
Analysis
Analysis
No intubation Bag Valve Mask ventilation
Follow ACLS Guidelines?
Begin IV 1 mg EPINEPHrine every 3 to 5 minutes
  • If adequate bystander chest compressions are
    provided, EMS providers perform immediate rhythm
    analysis and shock if indicated

30
Survival after Bystander CPR for OHCA in Arizona
(2005 to 2010) Compression Only CPR Advocated and
Taught
A.
B.
Witnessed/Shockable
All OHCA
35 30 25 20 15 10 5 0
33.7
AOR 1.6 (95 CI, 1.08-2.35)
P lt 0.001
Survival to Hospital Discharge
17.7
13.3
7.8
Std-CPR
COCPR
Std-CPR
COCPR
Bobrow, et al. JAMA 20103041447-1454
31
Neurological Intact Survival from CCRWitnessed
collapse and shockable rhythm
50 40 30 20 10 0
75/192
39/102
35/89
34/136
Neurologically Normal Survival to Hospital
Discharge
38
38
39
K.C. MO
Arizona
Rock and Walworth
Annals Emergency Med 2008
Annals Emergency Med 2009
Circulation 2009
32
Gasping Should Not Distract from Recognizing
Patient in Cardiac Arrest
  • EMD recordings of 445 witnessed cardiac arrests
  • Non-witnessed arrest 16 gasping
  • Witnessed arrest 55 gasping (p
    lt0.001)
  • Example of Gasping (Bondi Beach, YouTube)

Clark et al. Ann Emerg Med 1992211464
33
Medications proven to improve outcome in cardiac
arrest?

34
The priority is quality compressions
Reflected in the poor impact of ACLS meds
2009
Randomized trial of EPINEPHrine versus no
EPINEPHrine For EMS treated cardiac arrest ? NO
BENEFIT IN SURVIVAL TO DISCHARGE FROM HOSPITAL!
35
Bringing Science to the Pit CrewHigh-Functioning
EMS CPR Teams
  • The Pit Crew Approach

36
AHA 2010 Guidelines
  • C-A-B
  • Uninterupted chest compressions
  • Waveform capnography
  • Deemphasized
  • Intubation
  • Drugs
  • Mechanical CPR

37
Statewide Protocols 331A/ 3031AGeneral Cardiac
Arrest - Adult
  • Dont be fooled by agonal respirations
  • Cycles of 200 uninterrupted compressions
  • Early defib if good bystander CPR or EMS
    witnessed arrest

38
331A
  • 4 cycles of 200 compressions/ defib
  • Compressions cause passive ventilation
  • Medical director sets airway/ ventilation options

39
331A
  • After 4 cycles of 200 uninterrupted
  • compressions, add ventilations at 151
  • Indications for possible BLS field termination of
    CPR
  • Arrest not witnessed by EMS, AND
  • No ROSC/pulse prior to transport, AND
  • No AED shock delivered prior to transport

40
3031A
  • EPINEPHrine every 3-5 minutes
  • Antidysrhythmic if 2nd shock needed
  • Medical director sets airway/ventilation options
    for agency
  • Monitor capnography
  • Avoid intubation during initial cycles of
    compressions

41
3031A
42
3031A
  • Treat reversible causes
  • Pneumothorax
  • Hypovolemia
  • Appropriate medication
  • Antidysrhythmic
  • Mg for torsades (rare)
  • Calcium/bicarbonate in dialysis
  • Avoid inappropriate care
  • Naloxone
  • Glucose testing

43
High-Functioning CPR AgencyThe Pit Crew Team
44
Equipment organized to be efficient
45
Team member roles pre-assigned
46
Frequent practice/ simulation
47
Lets Examine a NASCAR Pit Crew
48
Team Leader AttributesNREMT
  • Creates, implements and revises an action plan
  • Communicates accurately and concisely while
    listening and encouraging feedback
  • Receives, processes, verifies, and prioritizes
    information
  • Reconciles incongruent information
  • Demonstrates confidence, compassion, maturity,
    (respect for team members), and command presence
  • Takes charge
  • Maintains accountability for teams
    actions/outcomes
  • Assesses situation and resources and modifies
    accordingly

49
Team Member AttributesNREMT
  • Demonstrates followership is receptive to
    leadership
  • Maintains situational awareness
  • Utilizes appreciative inquiry
  • Avoids freelance activity
  • Uses closed-loop communication
  • Reports progress on tasks
  • Performs tasks accurately and in a timely manner
  • Advocates for safety and is safety conscious at
    all times
  • Leaves ego/rank at the door

50
Pit Crew ApproachCompressions are Priority
  • Continuous chest compressions with minimal
    interruption are key
  • USE any available feedback device/ metronome
  • Alternate compressions between providers across
    patients chest (e.g. 100 each)
  • Chest compressions should continue when charging
    an AED or manual defibrillator
  • Chest compressions should resume immediately
    after any shock
  • Goal keep interruptions for rhythm
    check/defibrillation lt 10 seconds
  • Goal NO interruption for airway device insertion

51
Pit Crew ApproachThe Triangle of Life
52
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55
Pit Crew ApproachAirway Options During CPR
  • Airway insertion must not interrupt compressions
    !
  • Intubation deemphasized and should be delayed
    until after 800 compressions
  • Options with 3031A (set by medical director)
  • Naso/oropharyngeal Airway NRB oxygen
  • King LT/ Combitube oxygen

56
Pit Crew ApproachVentilation Options During CPR
  • Avoid Hyperventilation!
  • Options with 3031A (set by medical director)
  • No ventilation during initial 800
    compressions(with open airway, there is passive
    ventilation with compressions)
  • 1 ventilation/ 15 compressions
  • Monitor ventilation by capnography
  • ITD optional

57
Pit Crew ApproachBreathing / Ventilation Summary
  • Ventilation not needed during initial 4 cycles of
    CPR for PRIMARY CARDIAC ARREST
  • Ventilation still has role in
  • Pediatrics, lt15 y/o (152)
  • Secondary Cardiac Arrest (151)
  • Drowning
  • Hypoxic Cardiac Arrest
  • Suspected Respiratory Cause
  • Overdose, etc.

58
Pit Crew ApproachBreathing / Ventilation Summary
  • If BVM used,
  • 2-Person, 2-Thumbs-up
  • Technique Preferred

59
Pit Crew ApproachMedications During CPR
  • Routes
  • ? IO first line access
  • ETT ineffective
  • No role for checking labs
  • Role of medications
  • Epinephrine (IIb)
  • Ideally within first minute
  • Antidysrhythmic (IIb)
  • For refractory VF/VT

60
Pit Crew ApproachMechanical CPR Devices
  • Mechanical CPR devices do not lead to more
    survivors than manual CPR
  • Minimizing interruption in chest compressions
    during first 10 minutes of cardiac arrest is
    critical, so mechanical CPR device by BLS
    providers must be delayed until after the first 4
    cycles of uninterrupted compressions/defibrillatio
    n attempts

61
Real-time feedback examples
62
Pit Crew ApproachHow can we monitor our success?
  • Real-time feedback
  • Feedback from monitor/AED
  • Continuous waveform capnography
  • Post-code
  • Debriefing
  • QI Review
  • Benchmarking (Cardiac Arrest Registry for
    Enhanced Survival CARES)

63
Pit Crew ApproachHigh-functioning Team
  • Teamwork
  • Leadership
  • Situational Awareness (Roles)
  • Communication
  • Mutual Support
  • Role of Checklist
  • Designed for Efficiency/ Uniformity
  • Evidence-based
  • Perfect practice makes perfect
  • Initial training/ Simulation
  • Regular practice/ Simulation

64
High-Functioning CPR TeamContinuous Quality
Improvement
  • Each agency must adjust pit crew example diagram
    for local response
  • Number of responders
  • BLS and ALS
  • Device preferences
  • Medical director oversight
  • Must Measure Outcomes
  • PDSA Cycle (Continuous Improvement)
  • Plan Do Study Act
  • Small Tests of Change

65
Sequential improvement in Wake County, NC
66
3080 Post-resuscitation Care Checklist
  • Before moving patient
  • Augment marginal BP with IV fluid bolus and
    pressor drip
  • Obtain 12-lead ECG if possible
  • Titrate O2 to SpO2 between 95 99
  • Monitor continous ETCO2 and ventilation rate if
    advanced airway
  • Mask travels with bag-valve no matter what airway
    is in place
  • Package on backboard/firm surface
  • Is transport to center capable of PCI /
    hypothermia possible?

67
Conclusion
  • Improved Dispatch/Bystander CPR
  • High-quality uninterrupted compressions
  • NASCAR Pit Crew Approach to Cardiac Arrest
  • Transport to hypothermia/PPCI Center
  • QI Measure Our Outcomes
  • Celebrate Our Success !!

68
  • Thank You!
  • Dr. Gordon Ewy (Univ. of Arizona)
  • Dr. Benjamin Abella (Univ. of Pennsylvania)
  • for providing several slides to this presentation
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