Advanced

Resuscitation

Training

DANIEL DAVIS, MDPeople should not die

before they are done living.

What makes ART unique?• System of care

• Inpatient & prehospital

• Approach to education

• Cognitive psychology

• Curriculum breadth

• Reduce preventable death

• CQI data collection & analytics

• Six sigma-based

• Clinical outcomes

• Consistency across multiple institutions

System of Care

CQI

System of Care

Training Technology

Best

Practices Scientific

Evidence

Screening MonitoringEarly

recognition

Critical care

(including

procedural)

Arrest

resuscitation

Post-arrest

care

End-of-life

issues

Afferents

External

Internal

(Database)

Technology

Efferents

Special

projects

Training

The ART Enchilada

Screening MonitoringEarly

recognition

Critical care

(including

procedural)

Arrest

resuscitation

Post-arrest

care

End-of-life

issues

Afferents

External

• Scientific evidence

• Past performance

• Other institutions

• Manuals/guides

• Consensus opinion

• Best practices

• Guidelines

• Scientific evidence

• Past performance

• Other institutions

• Manuals/guides

• Consensus opinion

• Best practices

• Guidelines

• Scientific evidence

• Past performance

• Other institutions

• Manuals/guides

• Consensus opinion

• Best practices

• Guidelines

• Scientific evidence

• Past performance

• Other institutions

• Manuals/guides

• Consensus opinion

• Best practices

• Guidelines

• Scientific evidence

• Past performance

• Other institutions

• Manuals/guides

• Consensus opinion

• Best practices

• Guidelines

• Scientific evidence

• Past performance

• Other institutions

• Manuals/guides

• Consensus opinion

• Best practices

• Guidelines

• Scientific evidence

• Past performance

• Other institutions

• Manuals/guides

• Consensus opinion

• Best practices

• Guidelines

Internal

(Database)

• Arrest rates

• Patient diagnoses

• Comorbidities

• Arrest classifications

• Preventability

• Risk-adjusted mortality

• Process issues

• Arrest rates

• Patient diagnoses

• Comorbidities

• Arrest classifications

• Preventability

• Risk-adjusted mortality

• Process issues

• Arrest rates

• Diagnoses/comorbidities

• Arrest classifications

• Rapid response

• Preventability

• Risk-adjusted mortality

• Process issues

• Arrest rates

• Diagnoses/comorbidities

• Arrest classifications

• Preventability

• ICU/ventilator days

• Risk-adjusted mortality

• Process issues

• ROSC

• Survival-to-discharge

• Good neuro outcomes

• Arrest-related deaths

• Arrest classifications

• CPR process measures

• Process issues

• OOHCA survival

• ROSC-to-survival ratio

• Temperature management

• Facilitated PCI

• Neurocritical care

• ICU/ventilator days

• CLBSI/VAP rates

• Code:DNAR mortality

• Rate of 2+ Code Blues

• Advanced directives

• Family discussions

• Palliative care consultation

• Withdrawal

• Organ donation

Technology

• Manual vitals

• Monitor vitals

• Advanced monitoring

• Telemedicine

• Mechanical ventilation

• Circulatory assist devices

• Manual vitals

• Monitor vitals

• Advanced monitoring

• Telemedicine

• Mechanical ventilation

• Circulatory assist devices

• Manual vitals

• Monitor vitals

• MEWS/algorithms

• Advanced monitoring

• Telemedicine

• Mechanical ventilation

• Circulatory assist devices

• Manual vitals

• Monitor vitals

• MEWS/algorithms

• Advanced monitoring

• Telemedicine

• Mechanical ventilation

• Circulatory assist devices

• Monitor

• Defibrillator

• Mechanical compressor

• Circulatory enhancers

• Ventilation devices

• Temperature management

• ECMO

• Advanced monitoring

• Perfusion

• Oxygenation

• Ventilation

• Temperature management

• Percutaneous intervention

• Neurocritical care

• Advanced monitoring

• Computer algorithms

• Prognostication

• Palliative care

• Temperature management

• Compassionate extubation

• Family comfort

Efferents

Special

projects

• Triage/disposition

• Monitoring

• Screening approaches

• Telemedicine

• Hospital configuration

• Alternate care strategies

• Triage/disposition

• Monitoring

• Screening approaches

• Telemedicine

• Hospital configuration

• MEWS/algorithms

• Triage/disposition

• Monitoring

• Rapid response

• Critical care

• Procedures

• Non-arrest codes

• Triage/disposition

• Monitoring

• Screening approaches

• Telemedicine

• Hospital configuration

• Alternate care strategies

• Recognition

• Monitoring

• Equipment

• Code team configuration

• Protocols

• Medications

• Processes

• Advanced monitoring

• Equipment

• Neurocritical care

• Hospital configuration

• Protocols

• Palliative care

• Prognostication

• Monitoring/equipment

• Neurocritical care

• Hospital configuration

• Palliative care

• Prognostication

• Family issues

• Organ donation

Training

• Triage/disposition/monitoring

• ART Matrix

• Perfusion

• Oxygenation

• Ventilation

• Policies/protocols

• Peri-arrest

• Recognition

• Triage/disposition/monitoring

• ART Matrix

• Perfusion

• Oxygenation

• Ventilation

• Policies/protocols

• Peri-arrest

• Recognition

• Triage/disposition/monitoring

• ART Matrix

• Perfusion

• Oxygenation

• Ventilation

• Policies/protocols

• Peri-arrest

• Recognition

• ART Matrix

• Perfusion

• Oxygenation

• Ventilation

• Monitoring

• Procedures

• Peri-arrest

• Recognition

• Recognition

• Compressions

• Ventilations

• Medications

• Monitoring

• Defibrillation

• ROSC

• Rearrest

• ROSC

• POV

• Critical monitoring

• Temperature management

• Facilitated PCI

• Neurocritical care

• Reperfusion strategies

• End-of-life discussions

• Risk stratification

• Prognostication

• Patient/family discussion

• Conflict resolution

• Palliative care

• Ethics

• Organ donation

The ART Enchilada

Approach to Education

How We Teach

• Cognitive psychology

• Affective domain

• Conceptual learning

• Vertical perspectivism

• Pattern recognition

• Multiple modalities

• Integrated technology

Curriculum Breadth

What We Teach

• Arrest prevention

• The Theory of Everything

• Arrest resuscitation

• CPR Island

• Critical Care

• Integrated Model of Physiology

• Airway Management

• Advanced Airway Resuscitation Training

ARTNRP

ACLS/BLS

ATLS

PALS

ResuscitationAirway

Procedures

Critical CareVentilator

Specialty

VF/VT Vagal/block

Hemorrhage/

Hypovolemia

Tamponade/

Tension PTX

SepsisPE CHF

Lung DiseaseTracheostomy

ARDS Obstruction RSI

OtherTBI CVA

Circulatory Dysrhythmic Respiratory Neurologic

CancerImmobilizationCoagulopathy

Obesity

ProcedureCancer

AnticoagulationGI bleed

ICU

InfectionImmunocompromisedLines/catheters/tubes

Elderly/neonateShock

TraumaVentilator

COPD

Known CHFRenal failurePost-event

Lupus

Acute Coronary SyndromeCoronary Artery Disease

Known dysrhythmia

Movement (ICU)Stimulation (ICU)

Toilet Related DeathsHypervagal

TracheostomySecretionsBleeding

Known sleep apneaNarcotics/sedatives

Post-procedureSTOP BANG“Snorking”

Asthma/COPDKnown pulmonary disease

Pulmonary edemaPneumoniaOld/young

Undergoing RSIKnown ARDS

(ICU)

Known TBIPost-craniotomy

Known CVAVasculopathy

Anti-coagulationPost-craniotomy

Brain tumorElevated ICP

AVM

The Theory of Everything

SHOOT

Supine→IVF→Pressors→Blood

Etiology-specific therapy

VAD, ECMO

AIM

Vitals, labs, x-ray, other

SHOOT

Supine→IVF→Meds

Etiology-specific therapy

Pacing, shock

AIM

Exam, vitals, monitor, ECG

SHOOT

Upright→O2→BVM→PAP

Etiology-specific therapy

Intubation, ventilator

AIM

Vitals, labs, x-ray, other

SHOOT

Upright→osmotic→ventilation

Etiology-specific therapy

Burr, ventriculostomy, surgery

AIM

Exam, vitals, ICP, x-ray, other

Circulatory

Time

SBP

HR

COMPENSATED UNCOMPENSATED

Respiratory

Time

COMPENSATED UNCOMPENSATED

Tidal Volume

RRSpO2

GENERAL ARREST ALGORITHM

Oxygenation

Ventilation

Perfusion

Confirm

EtCO2

Chest rise

Breath sounds

SpO2

Ma

xim

ize

1stA

tte

mp

t

Pre

ve

nt

Hypoxic

Arr

est

Ove

rall

Intu

ba

tio

n

Su

cce

ss

BVM1 until return

of spontaneous

respirations

SaO2>93%

Anticipate

problem

Unsuccessful7

Successful

Successful

Abandon attempt6

SaO2>93%“Can’t intubate,

can oxygenate”

SaO2<93%“Can’t intubate,

can’t oxygenate”

Partial response

to BVM

Not responding

to BVM

Successful

Unable to

intubate

Unsuccessful

Successful

1Two thumbs up” BVM, cricoid pressure, NPA/OPA, EtCO22Hypoxemia, Extremes of size, Anatomic disruption/obstruction,

Vomit/blood/fluid, Exsanguination, Neck mobility (HEAVEN)3VL or DL without paralysis, primary supraglottic/cric4Paralytics contraindicated with suspected airway obstruction5VL (TBI/trauma/anatomic/extremely large) vs. DL (fluids/speed/extremely small)6SpO2 dropping below 93%, recognition of better alternative, bradycardia7Consider repeating RSI medications

Normal

Able to

intubate

NRB

1-3”Preoxygenate

with NRB +/- NC

Assisted

ventilation

(small volume)1

Pre-

assessment2

•Consider alternative approach3

•Access adjuncts

•Access cric kit

•Cric pressure

•Sedative

•Paralytic4

SaO2>93%

BVM

(large volume)1

•1st Look5

•External laryngeal

manipulation (ELM)

1st Attempt

SaO2

<93%

ELM

VL, DL (Shoehorn)

Supraglottic

Magills

Bougie

Cric

Rapid Airway

Access

Supraglottic

Cric

Brief

attempts

Unsuccessful

Suction

Supraglottic

Cric

BVM1/temp supraglottic(Consider other intubator

or immediate transport)

ELM

VL, DL (Macler)

Bougie

CQI Data/Analytics

ART Data/Analytics• Institutional

• Operational

• Demographics

• Antecedent events

• Intra-arrest

• Post-arrest

• Process issues

• Clinical interpretation

Clinical Outcomes

Need Graph, %

0% 1% 2%

88%

81% 82%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Case 62 (pre) Case 65 (pre) Case 55 (pre) Case 74 (post) Case 72 (post) Case 71 (post)

Pre ART Post ART

CC

F (

%)

Los Angeles EMSA

ccep

tab

le C

om

pre

ssio

ns (

%)

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

score w/o score with feedback

Compressions in Target

Before After

80

82

84

86

88

90

92

94

96

98

100

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

IntubationSuccess(%)

2015 2016 2017

Overall

First Attempt

First AttemptwithoutDesaturation

Air Methods Intubations

0

5

10

15

20

25

30

35

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

ROSC(%

)

RVCFDArrestOutcomes

20182017201620152014

Riverside County FD

0

5

10

15

20

25

30

35

40

SurvivaltoEDAdmission

Survival(%

)

ColtonFD

Pre-ART

Post-ART

0

5

10

15

20

25

30

35

40

45

50

2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13

ArrestSurvival

Su

rviv

al-

to-D

isch

arg

e (

%)

Current U.S. Benchmark

UCSD Arrest Survival

0

0.5

1

1.5

2

2.5

3

2006-07 2007-08 2008-09 2009-10 2010-11 2011-12

Non-ICUArrests

Arr

est

Incid

en

ce (

per

1000 a

dm

issio

ns)

UCSD Non-ICU Arrest Incidence

1.4

1.5

1.6

1.7

1.8

1.9

2

2.1

2.2

2005-06 2006-07 2007-08 2008-09 2009-10 2010-11

OverallHospitalMortality

Ho

sp

ital

Mo

rtality

(%

of

Ad

mis

sio

ns

)

UCSD Hospital Mortality

0

10

20

30

40

50

60

70

80

90

100

TargetRate TargetDepth CCF ROSC Survival GoodNeuro

Percent(%)

MayoFlorida

Pre-ART

Post-ART

Mayo Florida Arrest Survival

0

5

10

15

20

25

30

35

40

45

2015 2016 2017

SurvivaltoDischarge(%

)

GeisingerMedicalCenterGeisinger Arrest Survival

0

10

20

30

40

50

60

Sep/Oct Nov/Dec Jan/Feb Mar/Apr May/Jun Jul/Aug

Non-ICUArrests(#)

OchsnerMedicalCenter

Pre-ART

Post-ART

Ochsner Arrest Incidence

An ART Movement

0

10

20

30

40

50

60

70

80

UCSD VA OtherUC's Mayo ED

Witnessed

CPRon

Arrival

AirMedical Santa

Barbara

ElCajon San

Bernardino

Riverside

Survival(%

)

Pre-ART

Post-ART

Inpatient ED Air Ground EMS

danieldavismd@gmail.com