Refresher Training:Adult CPR and the

ResQ Trial in Whatcom County

Prepared byJanice Lapsansky

July 2009

Topics

Adult CPR1

2 ResQ Trial Refresher

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 AHA guidelines.

5. Describe the correct performance of active compression-decompression (ACD-CPR) with the ResQ Pump and ResQ POD, including methods of troubleshooting difficulties.

6. Describe the information needed to complete the hotline report.

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) – a 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 notnot 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 right after I deliver a shock?

1

No stacked shocks

No pulse check after shock

1. single shock2. 2 minutes of CPR3. pulse check4. re-analyze if no pulse

Defibrillation

This reduces the “no flow time”. Why is this important?

Defibrillation

• EMS-witnessedwitnessed 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

How can I get the best seal using the King facemask provided in the study packs?

Rescue Breathing During CPRwith an Advanced Airway

1

• ET tube, Combi-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 more than 10 seconds

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

Successful CPR

• All sites have measured an increase in successful resuscitations.

• The improved outcome for our patients could be due to• more frequent CPR training,• better Standard CPR,• CPR with the ResQ Pump and ResQ POD,

or• all three of these reasons!

• We do know that rescuers are doing a great job at• limiting pauses in chest compressions• managing the airway (facemask seal, rate

and depth of rescue breaths) • using the AED

1

How often should rescuers practice their CPR skills?

ResQ Trial Refresher2

ResQ Trial Research Question

Is it possible to provide more effective CPR with one or both of these CPR 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 draws blood back into

the chest and heart,the chest and heart,• increases coronary increases coronary

artery blood flow,artery blood flow,• decreases intracranial decreases intracranial

pressure and pressure and increases blood flow increases blood flow to the brain during to the brain during CPR!CPR!

Note: The ResQ Pump is designed to create this vacuum more effectively than chest recoil alone when using a pair of hands.

Decompression Phase, cont'd2

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

…the more that is pushed 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 these CPR Tools

2

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 ResQPODduring CPR

2

Compression Ventiliation

Airflow Through the ResQPODduring CPR

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 CPR for intubation or AED

— 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• Lightning/Electricity

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• Rotate compressor every 2 minutes!

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, Combi-tube, 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 depth as in standard CPR• Compress the

chest 1 ½ - 2” (65-90 lbs on strain gauge)

• 80 compressions per minute

• Body position is critical to avoid fatigue

• Do not straddle patient

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

2ACD-CPR + ITD - Facemask

Only• Place ResQ POD & ResQ Pump within first 2

minutes of CPR• Perform compressions with ResQ Pump @

80/min (metronome)

How do I avoid fatigue and injury while performing ACD-CPR?

2

Two-Person CPR

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

Stretch the cuff on the facemask to improve the seal. Hold in place by using the fingers of both hands to bring the jaw to the facemask (rather than pushing the facemask down onto the face).

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 do I do if the timing lights don’t turn on?

ETCO2 Monitoring

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

2

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

Call to the Research Hotline

• 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.—Signs of increased LOC during CPR

• 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).

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…Thank you for 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

back

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.

• If the arrest was not witnessed by EMS, 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

Stretch out the cuff on the King facemask to

improve the seal. Hold in place with 2 hands.

Stretch out the cuff on the King facemask to

improve the seal. Hold in place with 2 hands.

back

When squeezing the bag, bring the fingertips of one

hand together.DO NOT increase volume!

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.

back

Attempt to time ventilations between chest compressions during CPR.

Decompression Phase

back

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

Knowledge and skills decrease only Knowledge and skills decrease only 10 weeks after completion of training10 weeks after completion of training

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

Knowledge and skills decrease only Knowledge and skills decrease only 10 weeks after completion of training10 weeks after completion of training

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

back

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

back

Chest Compression w/ ResQ Pump

Center the ResQ Pump at the mid-nipple line of the sternum. Compress the chest using the strain gauge as a

guide: 65-90 lbs

Center the ResQ Pump at the mid-nipple line of the sternum. Compress the chest using the strain gauge as a

guide: 65-90 lbs

back

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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ResQ POD Troubleshooting3

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The timing assist lights are independent of inspiratory impedance function.

• If timing assist lights fail to operate or appear to blink at a rate different than 10/minute, keep POD in place and ventilate the patient at 10/minute• approx 10:1 compression to ventilation ratio

during S-CPR; or 8:1 during ACD-CPR• Discontinue use (and replace with 2nd ResQ POD) if:

• Chest does not rise with ventilation• Device appears to malfunction in any way

AED

• 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

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

back

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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The 2 components of Cardiac Output

High quality CPR must focus on

• Heart Rate (HR)• Compress the chest at 100x/min in standard CPR• Compress the chest with the ResQ Pump at 80x/min

• Stroke volume (SV)• The heart must fill adequately between

compressions• negative pressure created as the chest expands

returns more blood to the heart, so the next chest compression is more effective!

Adequate HR and SV ensure adequate perfusion of the brain and coronary circulation

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

back

Avoid fatigue and injury…

Rock your body back and forth, bend at the waist,

keep arms straight

Rock your body back and forth, bend at the waist,

keep arms straight

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Rotate the compressor every 2 minutes!