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Refresher Training: The ResQ Trial in Whatcom County. Prepared by Janice Lapsansky January 2008. Topics. Adult CPR. 1. ResQ Trial Refresher. 2. Click on this icon to reveal the answers to test preview questions . Learning Objectives.

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Refresher training the resq trial in whatcom county

Refresher Training:The ResQ Trial in Whatcom County

Prepared by

Janice Lapsansky

January 2008


Topics
Topics

Adult CPR

1

ResQ Trial Refresher

2

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


Learning objectives
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:

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

  • List the patient inclusion/exclusion criteria.

  • State the purpose of the randomization calendar and the method your agency uses to insure the calendar is followed correctly each week.

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

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

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


Terms
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 measured 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 Combi-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 cpr

1

Adult CPR


Abc s
ABC’s

  • Open the airway

  • Check for breathing

    • Look, listen, and feel

  • Check for circulation


Opening the airway

1

Opening the Airway

head-tilt / chin-lift

  • For all victims unless cervical spine injury is suspected.


Opening the airway1

1

Opening the Airway

head-tilt / chin-lift

  • Without head extension where cervical spine injury is suspected.

jaw thrust

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


Quality cpr w bvm

1

Quality CPR w/ BVM

  • The compression to ventilation ratio is 30:2

  • The ventilation rate during CPR is 1 breath every 6-8 seconds

    Is this faster or slower than

    the rate of rescue breathing?

  • Deliver each rescue breath quickly (1 sec) with visible chest rise

  • Provide immediate chest compressions

AHA says:


Hand placement

1

Hand Placement

  • Use the mid-nipple line for adults and children

Rock the heel of the hand off the chest, keeping fingertips on chest wall to maintain hand position.

During CPR, how often should the rescuer performing chest compressions be rotated out?


Aed defibrillation

1

AED & Defibrillation

Cardiac arrest not witnessed by EMS:

  • Perform 5 cycles or 2 minutes of CPR before analyzing rhythm

When should the defib pads be applied to the patient?

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


Defibrillation

1

Defibrillation

No stacked shocks

No pulse check after shock

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

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


Defibrillation1
Defibrillation

  • EMS-witnessed Arrest:

    • Use AED first in adult victims when AED is immediately available.

What will you do immediately after the first shock is delivered?

  • Unwitnessed Arrest:

    • 5 cycles or 2 minutes of CPR, beginning with chest compressions.


Cpr and rescue breathing with a bag valve mask bvm

1

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

  • 30:2 compression to ventilation ratio

  • Hold tight, two-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 more quickly, will you also give a larger volume of air with each breath?


Rescue breathing during cpr with an advanced airway

1

Rescue Breathing During CPRwith an Advanced Airway

  • ET tube or Combi-tube

  • Ventilations at 8-10 times per minute, or approximately every 6-8 seconds

  • For all victims in cardiac arrest

Should you pause chest compressions

to deliver breaths after tube placement?


Quality of chest compressions

1

Quality of Chest Compressions

  • Push hard, push fast

  • Adult compressions must be 1 ½ - 2 inches deep

  • Standard rate 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

1

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 (DO NOT hyperventilate!)

  • Use defibrillation appropriately

How often should rescuers practice their CPR skills?


Resq trial overview

2

ResQ Trial Overview


Resq trial research question

2

ResQ Trial Research Question

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


Resq trial research question1

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

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


Cardiac pump component

2

Cardiac Pump Component

  • Blood flow during CPR is due to the direct compression of the heart between the sternum and the spine.

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


Thoracic pump component

2

“Thoracic Pump” Component

  • During chest compression, increased pressure in the chest, aided by one-way valves in the heart and veins, causes forward movement of blood through the circulatory system.

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


Decompression phase

2

Decompression Phase

  • The ribs and sternum act as a bellows.

  • As the chest expands, a vacuum is created.

  • Blood returns to the heart during this relaxation (decompression) phase.


Decompression phase cont d

2

Decompression Phase, cont'd

  • This small, but important, vacuum (negative pressure)

    • draws blood back into the chest toward the heart

    • Increases blood flow into the chambers of the heart


Decompression phase cont d1

2

Decompression Phase, cont'd

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

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

    • increases blood flow to the brain

    • increases blood flow through the arteries of the heart


Refresher training the resq trial in whatcom county 1335544

  • “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 tools

2 allows blood to return to the heart

Sustains the vacuum that is created (with a tight facemask seal)

Together, enhance the negative pressure in the chest during the decompression phase of CPR in order to return more blood to the heart.

=

Mechanisms of CPR Tools

Begins creation of the vacuum


Resq trial calendar

2 allows blood to return to the heart

ResQ Trial Calendar

  • The treatment for the week is decided ahead of time to reduce the chance of bias and to strengthen the results.

  • The study week begins on Sunday at 8am.

What is the method used by your agency to insure that the correct devices are stocked on rescue vehicles on Sundays at 8am?


Resq trial calendar1

2 allows blood to return to the heart

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

    • If a “yellow” week, use the ResQ POD pre-loaded on the facemask & ResQ Pump immediately, or within the first 2 minutes of CPR

      • Do not delay for intubation or other procedures

    • Report any problems during the hotline call

Where can you find the phone number for the ResQ Trial hotline?


Inclusion criteria

2 allows blood to return to the heart

Inclusion Criteria

Adults known or presumed to be ≥ 18 yrs

Presumed non-traumatic* cardiac arrest, such as:

  • Cardiac etiology

  • Respiratory etiology

  • Stroke

  • Overdose

  • Smoke inhalation

  • Drowning

  • Burns

  • Metabolic imbalance

  • Seizures

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


Exclusion criteria

2 allows blood to return to the heart

Exclusion Criteria

Known or presumed < 18 years

Obvious or likely traumatic etiology

Penetrating or blunt trauma

Pre-existing DNR orders

Obvious signs of clinical death (DOA)

Family members who request exclusion

For ACD-CPR+ITD arm: recent sternotomy (wound not appearing completely healed or, if known, < 6 months)

If the patient meets ANY of the exclusion criteria, perform Standard CPR.


Study protocol 3100 patients

2 allows blood to return to the heart

Study Protocol—3100 patients

Cardiac arrest

outcome


Study protocol 3100 patients1

2 allows blood to return to the heart

Study Protocol—3100 patients

Cardiac arrest

outcome

S-CPR

ACD-CPR + ITD

  • Randomized by week


Study protocol 3100 patients2

2 allows blood to return to the heart

Study Protocol—3100 patients

Cardiac arrest

outcome

S-CPRACD-CPR + ITD

  • Randomized by week

  • Defibrillation

  • Intubation

  • IV & medications

  • Standard

  • treatment


Study protocol 3100 patients3

2 allows blood to return to the heart

Study Protocol—3100 patients

Cardiac arrest

outcome

S-CPR

ACD-CPR + ITD

  • Randomized by week

  • Defibrillation

  • Intubation

  • IV & medications

  • Standard

  • treatment

=

outcome


Cpr success1

2 allows blood to return to the heart

CPR Success

  • Follow the correct compression rates:

    • S-CPR: 100/min

    • ResQPump: 80/min

  • Allow chest to completely recoil

  • Do not hyperventilate!

  • Facemask: 30:2 compressions to vents

  • Advanced airway: 8-10/min

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


Run follow up

2 allows blood to return to the heart

Run Follow-up

  • 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.

  • 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).


Run follow up continued

2 allows blood to return to the heart

Run Follow-up, continued

  • 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.


Standard cpr facemask only

2 allows blood to return to the heart

Standard CPR—Facemask Only

  • Airway not secured (facemask)

    • Compress @ 100/min

    • Pause for breaths

    • Compression to ventilation ratio 30:2

Is this the correct compression rate?


Standard cpr advanced airway

2 allows blood to return to the heart

Standard CPR—Advanced Airway

  • Airway secured (ET or Combi-tube)

    • Continuous compressions @ 100/min

    • Do not pause for breaths

    • Ventilate at 10/min (once every 10 compressions)


Refresher training the resq trial in whatcom county 1335544

2 allows blood to return to the heart

Two-Person Rescue Breathing with a BVM

Maintain a tight, two-handed facemask seal.

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


Refresher training the resq trial in whatcom county 1335544

2 allows blood to return to the heart

ACD-CPR + ITD—Facemask Only

  • ResQPump & study package with facemask, ResQPOD & sticker

  • Place ResQPOD & ResQPump withinfirst 2 minutes of CPR

  • Perform compressions with ResQPump @ 80/min (metronome)

  • Pause for breaths

  • Compression to ventilation ratio 30:2

  • Compress to 1.5 - 2” with active decompression (use gauge)

When should the ResQPOD’s lights be used?


Refresher training the resq trial in whatcom county 1335544

2 allows blood to return to the heart

ACD-CPR + ITD—Advanced Airway

Compress continuously @ 80/min (metronome)

Do not pause for breaths

Compress to 1.5 – 2” with active decompression (use gauge)

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?


Etco 2 monitoring

2 allows blood to return to the heart

ETCO2 Monitoring

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


Troubleshooting

2 allows blood to return to the heart

Troubleshooting

  • 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 10 breaths/minute.


Troubleshooting cont d

2 allows blood to return to the heart

Troubleshooting, cont'd

Discontinue ResQPOD 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)


Refresher training the resq trial in whatcom county 1335544

2 allows blood to return to the heart

ResQPOD Fills With Fluid

  • 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.


Refresher training the resq trial in whatcom county 1335544

2 allows blood to return to the heart

ResQPOD Fills With Fluid, cont'd

  • 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 researcher coordinator.


Acd cpr compression

2 allows blood to return to the heart

ACD-CPR Compression

  • Same objective as in standard CPR

  • 1 ½ - 2” in depth (65 - 90 lbs)

  • 80 compressions/minute

  • Body position is critical to avoid fatigue

  • Do not straddle patient

  • Rotate compressor role every 2 minutes.

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


Refresher training the resq trial in whatcom county 1335544

2 allows blood to return to the heart

Troubleshooting ACD-CPR

  • 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 every 2 minutes

When using the ResQPump, how hard should a

rescuer pull up (decompress the chest)?


Refresher training the resq trial in whatcom county 1335544

2 allows blood to return to the heart

Troubleshooting ACD-CPR, cont'd

  • Rib fractures

    • Check placement and continue

  • Hickey or bruising to chest

    • Continue

  • Discontinue use if device appears to malfunction.


Cleaning reuse

2 allows blood to return to the heart

Cleaning/Reuse

  • Clean cup with soap and water.

  • May be cleaned with bleach solution or other disinfectant.

  • Check gauge for proper calibration.


Untrained healthcare providers

2 allows blood to return to the heart

Untrained Healthcare Providers

Do not leave the ResQPOD or ResQPump in the hands of healthcare providers who have not been trained in their use.


Refresher training the resq trial in whatcom county 1335544

Finally… allows blood to return to the heart

Give both CPR methods the greatest opportunity to work…

Do the best CPR possible!


Written test

2 allows blood to return to the heart

Written Test

Click here to return to the start of thispresentation…

or

Close this window and click the ResQ Trial exam link on the main course page.


Ventilation during cpr
Ventilation During CPR allows blood to return to the heart

  • The ventilation rate during CPR is 1 breath every 6-8 seconds

    This is slower than for rescue breathing alone.

  • Rescue breathing (without CPR) is 12 times per minute (every 5 seconds)

back


Aha says
AHA says… allows blood to return to the heart

“Push hard and push fast”

  • A faster compression rate (that allows full chest recoil) produces the blood pressure required to send blood to the brain and heart muscle.

  • Adequate compression depth before each shock directly affects shock success – deeper compressions lead to more successful shocks

    • Resuscitation. 2006; epub, September 16

back


Fatigue factor

1 allows blood to return to the heart

Fatigue Factor

  • Change roles every 2 minutes (5 cycles)

  • Regardless of whether you feel tired!

  • Switch quickly to avoid interruptions in CPR

back


Apply the aed
Apply the AED allows blood to return to the heart

  • 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

back


Appropriate defibrillation

1 allows blood to return to the heart

Appropriate Defibrillation

No stacked shocks

No pulse check after shock

Do not interrupt CPR for rhythm analysis or defibrillation for long periods of time. During these “no flow times” the brain and heart are not receiving oxygen in the blood. Prolonged no flow times decrease the chance that defib will work!

back


Following each shock
Following each shock allows blood to return to the heart

Immediate chest compressions of good quality will supply blood to the heart muscle that will help it respond better to medications and AED shocks

back


Cpr and rescue breathing with a bag valve mask bvm1

1 allows blood to return to the heart

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

Deliver each breath over 1 second, with visible chest rise.

DO NOT increase volume!

back


Rescue breathing after intubation
Rescue Breathing after Intubation allows blood to return to the heart

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

back


Decompression phase1
Decompression Phase allows blood to return to the heart

Assure that the chest wall recoils completely after each compression in order to maximize the formation of the vacuum that promotes filling of the heart.

back


Practice your cpr skills frequently
Practice your CPR skills frequently allows blood to return to the heart

Good CPR takes training AND practice

  • Research shows that students continue to show improvement in both knowledge and skills after 4 training sessions

  • Understanding and skills begin to weaken after only 10 weeks following training

  • Rescuers should practice their skills 3-4 times per year

  • Plan to practice with the manikin and other training materials on your own or with a partner for ~10 minutes each month

back


Bls als work together to save lives
BLS & ALS work together to save lives! allows blood to return to the heart

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 depth
Chest Compression Depth allows blood to return to the heart

Compress the chest 1 ½ - 2”

(65-90 lbs on strain gauge)

back


Refresher training the resq trial in whatcom county 1335544

1 allows blood to return to the heart

Blood Flow to Vital Organs During Chest Compressions

Interruption in chest compressions

0

5

10

15

20

25

30

0

0

0

0

5

Compressions

Perfusion

Perfusion Needed

Forward blood flow is accomplished beginning with 15 chest compressions, and sustained until compressions are paused for ventilations.

“no-flow time”

back


Resq trial hotline
ResQ Trial Hotline allows blood to return to the heart

You can find the hotline phone number in:

  • Resource Guide (yellow folder)

  • Easy-to-Read ResQ Trial Calendar

    Call the hotline after every cardiac arrest (including peds, trauma victims, & DOAs).

    Research Hotline: 1-866-640-2832

back


Study protocol

2 allows blood to return to the heart

Study Protocol

Cardiac arrest

EMS performs a minimum of 30 minutes of CPR in all study arms

outcome

S-CPR

ACD-CPR + ITD

  • Randomized by week

  • 1033 patients per group

  • Defibrillation

  • Intubation

  • IV & medications

  • Standard

  • treatment

=

back

outcome


Refresher training the resq trial in whatcom county 1335544

2 allows blood to return to the heart

ResQPOD with an ET Tube

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

back


Refresher training the resq trial in whatcom county 1335544

2 allows blood to return to the heart

The ResQPOD enhances circulation.

When pulse returns…

The ResQPOD is a CPR tool

Keep the ResQ POD nearby in case the patient re-arrests.

back


Refresher training the resq trial in whatcom county 1335544
AED allows blood to return to the heart

  • 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

back


Acd cpr decompression

2 allows blood to return to the heart

ACD-CPR Decompression

Lift until force gauge reads approx: -20 lbs.

Most common error is failure to actively decompress chest.

back


Compressions at a rate of 100 min
Compressions at a rate of 100/min. allows blood to return to the heart

YES! This is approximately 100 compressions per minute.

back

OR…you can hum the “Staying Alive” song