Adult CPR and the ResQTrial Prepared by Janice Lapsansky Spring 2006
Agenda • Major Changes in AHA guidelines for adult CPR • ResQ Trial overview • Study objectives • Patient inclusion/exclusion criteria • Randomization schedule • Study protocol • Manikin practice and skills evaluation • Standard CPR with modified hand position • Use of an impedance threshold device (ResQ POD) • Performance of active compression-decompression (ACD-CPR) with the ResQ Pump and ResQ POD (Note: a new ResQ Trial training video is being produced)
Major Changes in Adult CPR • Compression to ventilation ratio (30:2 for all levels of rescuers) • Ventilation rate changes in CPR • Each rescue breath is delivered more quickly (1 second) • Emphasis on immediate chest compressions and improved technique • AED shock cycle changes • Opening the airway
Phone First or CPR First?Tailor The Sequence to Meet the Need • Lone HCP will do CPR First • On a victim of any age, including adult, when the cause is likely do to hypoxic (asphyxial) arrest (e.g. drowning, drug overdose). • Do 5 cycles or 2 minutes of CPR, then activate EMS • Lone HCP will Phone First: • On an unresponsive adult, when collapse is most likely cardiac in origin. 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
Opening the Airway • Open the airway using “head tilt, chin lift” on trauma victims, unless cervical spine injury is suspected. Use the jaw thrust without head extension for suspected C-spine. If the jaw thrust does not adequately open the airway, use the head tilt, chin lift as airway takes priority for theunresponsive trauma victim. • Manual stabilization of the C-spine is preferred over mechanical devices.
Rescue BreathingWithout Chest Compressions • No major changes to rescue breathing, but wider range allows rescuer to tailor respiratory support Adults - 10/12 breaths/min (1 per 5-6 sec) 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
Rescue Breathing during CPR • Deliver each breath over 1 second, with visible chest rise • DO NOT increase volume! • BVM: 30:2 compression to ventilation ratio • hold tight facemask seal • count out loud (“1 and 2 and 3 and…”) • pause after 30 compressions for delivery of two rescue breaths when ventilating with BVM • Advanced Airway: ET tube, Combi/EZ tube - ventilations should be given 8-10 times per minute, or approximately every 6-8 seconds for all victims in cardiac arrest (adult, child, and infant) • Do not pause chest compressions to deliver breaths
Quality of Chest Compressions • Proper technique when delivering chest compressions absolutely critical • Emphasize “push hard, push fast” • Adult compressions must be 1 ½ - 2 inches deep • Picture the heart being compressed b/w sternum and spine • Rate must be 100/min • Do not interrupt chest compressions for longer than 10 seconds (e.g. to give rescue breaths; or to analyze rhythm) • Must allow full chest recoil after each compression.
Fatigue Factor • Rescuers must change positions after every 2 minutes, or 5 cycles, of CPR to maintain proper quality • Regardless of whether you feel tired! • Rescuers should switch quickly to avoid any interruptions in CPR quality.
Hand Placement • Use the mid-nipple line for adults and children When using two-hand technique, rock the heel of the hand off the chest using fingertips on chest wall to maintain hand position
Defibrillation • Elimination of consecutive (“stacked”) shocks • Single shock will be followed by 2 minutes of CPR, then pulse check, and re-analyze if necessary • Altered protocol for witnessed versus unwitnessed arrest • With “EMS-witnessed arrest” – Use AED first in adult victims when AED is immediately available • If EMS does not witness the arrest, then do 5 cycles or 2 minutes of CPR, beginning with chest compressions. • Immediate chest compressions of good quality will supply blood to the heart muscle that will help it respond better to medications and AED shocks!
Relief of Foreign Body Airway Obstruction • Terminology change only- • Delete the 3 categories of: partial airway obstruction with GOOD air exchange, partial airway obstruction with POOR air exchange, and complete obstruction to: • Mild airway obstruction • Severe airway obstruction
ResQ Trial Research Question: Is it possible to provide more effective CPR with one or both of these CPR tools, as compared to standard CPR? • Patient Survival • Neurologic health (and quality of life)
“Cardiac Pump” Component Blood flow during CPR is due to the direct compression of the heart between the sternum and the spine. May play particularly important role only during the early phases of CPR (valves become less effective after prolonged arrest).
“Thoracic Pump” Component:Compression Phase During chest compression, increased pressure in the chest, aided by one-way valves in the heart and venous system, cause forward movement of blood through the circulatory system.
Decompression Phase • Ribs & sternum act as a bellows. • Blood returns to the heart during the relaxation (decompression) phase. • A small, but important, vacuum (negative pressure) forms in the chest and draws blood back into the chest and heart. • The more blood that returns to the heart (preload), the more that is circulated forward (cardiac output) with the next chest compression.
“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 Goal: Enhance the negative pressure (or vacuum) in the chest during the decompression phase of CPR in order to return more blood to the heart. ResQPump: Begins the creation of the vacuum ResQPOD: Sustains the vacuum that is created, either by elastic recoil of chest wall or by ResQPump
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 • Patients will be analyzed according to the treatment that they should have received, not what they actually got. • Follow the schedule exactly • Implement the devices ASAP – do not delay! • Report errors
Inclusion Criteria • Adults known or presumed to be ≥ 18 yrs • Presumed non-traumatic* cardiac arrest • Cardiac etiology • Respiratory etiology • Stroke • Overdose • Smoke inhalation • Drowning • Burns • Metabolic imbalance • Seizures • *If you are uncertain, presume it is non-traumatic until you discover otherwise
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 • 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, follow traditional standard operating procedures.
Study Protocol (3100 pts) Cardiac Arrest Randomize by week S-CPR S-CPR + ITD • Standard Treatment • Defibrillation • Intubation • IV & medications 1033 patients per group Outcome ACD-CPR + ITD
Exceptional CPR Quality • Follow correct compression rates: • S-CPR: 100/min • ACD-CPR: 80/min • Allow chest to completely recoil • Do not hyperventilate • Facemask: 30:2 compression to ventilation ratio • Maintain tight seal at all times; do not interrupt chest compressions for placement of advanced airway • Advanced airway: 8-10/min • Provide rescue breaths over 1 second that produce visible chest rise • Avoid interruptions of CPR longer than 10 sec. • Attempt EMS-provided resuscitation for a minimum of 30 minutes for ALL STUDY ARMS
Run Follow-up • Complete patient care record accurately • Attempt to record times that CPR starts/stops, time of Pump and POD use, time of intubation, etc. • Print code summary • Call in to research hotline (24/7) • 1-866-640-2832 • ALL ARRESTS; regardless of whether entered and regardless of resuscitation attempted • ResQPOD: place sticker on run report • dispose of ResQPOD unless there were problems; replace with new • ResQPump: record number on run report • clean ResQPump and reuse
Standard CPR (S-CPR) • Package with facemask only • Airway not secured (facemask) • Compression to ventilation ratio 30:2 • Compress to 1.5 - 2” & allow complete recoil with modified hand position • Compress at rate of 100/min but pause for breaths • Ventilate over 1 second • Airway secured (ET or Combi-tube) • Compress continuously @ 100/min; do not pause for breath • Compress to 1.5 – 2” & allow complete recoil with modified hand position • Ventilate at 8-10/min (1 breath about every 6-8 seconds) • Ventilate over 1 second
Standard CPR + ResQPOD • Package with facemask, ResQPOD, adaptor & sticker • Place ResQPOD on facemask ASAP • Airway not secured (facemask) • Compression to ventilation ratio 30:2 • Compress to 1.5 - 2” & allow complete recoil with modified hand position • Compress @ 100/min; pause for breaths (less than 10 sec) • Ventilate over 1 second • Airway secured (ET tube or Combi-tube) • Compress continuously @ 100/min; do not pause for breaths • Compress to 1.5 – 2” & allow complete recoil with modified hand position • Move ResQPOD to airway and turn on timing assist lights • Ventilate according to lights or 8-10 breaths/min • Ventilate over 1 second
Hand placement to maintain a tight seal Two-person rescue breathing* One person rescue breathing *The two-handed technique is preferred. When it’s time to pause compressions to give the breaths, the person doing chest compressions can reach over and squeeze the ventilation bag.
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. (Disconnect the ResQPOD to deliver meds thru ET tube, then reconnect and continue ventilations.)
ACD-CPR + ITD • ResQPump & package with facemask, ResQPOD adaptor & sticker • Place ResQPOD on facemask ASAP • Airway not secured (facemask) • Compression to ventilation ratio 30:2 • Compress to 1.5 - 2” with active decompression (use gauge) • Use ResQPump & compress @ 80/min (metronome); pause for breaths (less than 10 sec) • Ventilate over 1 second • Airway secured (ET 1st choice) • 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 • Ventilate over 1 second
If CPR is in progress… When pulse returns…
ETCO2 Monitoring Place the ETCO2 sensor between the ventilation source and the ResQPOD.
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 10/minute, disregard the lights, continue using the ResQPOD, and ventilate the patient at 8-10 breaths/minute. • 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)
TroubleshootingResQPOD 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. • May replace POD with new one (preferred), or d/c completely • Suctioning of tube (w/o fluid in POD) does not require that the POD be discontinued • If any problems with the ResQPOD, save in a red bag and return to researchers
ResQPump™ Metronome Force Gauge Suction Cup Handle
ACD-CPRCompression • Same as standard CPR • 1 ½ - 2” Body position is critical to avoid fatigue. Do not straddle patient. Rotate compressor role @ every 2 minutes.
ACD-CPRDecompression • Lift until force gauge reads approx. –20 to –30 lbs Most common error is failure to actively decompress chest
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 frequently • Rib fractures • Check placement and continue • Hickey or bruising to chest • Continue • Discontinue use if device appears to malfunction.
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 Do not leave the ResQPOD or ResQPump in the hands of healthcare providers who have not been trained in their use.
Q u t i e o s n s ?