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OHCA - From the Field to the
Hospital: Best Practices
Cardiovascular Care Summit
Matthew Sholl, MD, MPH, FACEP
What We Know About Cardiac
Arrest• Minutes matter!
– Mortality increases 10% with each minute the
heart remains in arrest
• Care must begin immediately!• Care must begin immediately!
– Best survival seen in patients who arrest in
public and have access to early defibrillation
• Cardiac arrest care must be highly sequenced!
– Many steps + must be highly organized
Outline and Objectives
• General Comments
• Evidence Evaluation Process
• Adult BLS Update
• Adult ALS Updates• Adult ALS Updates
• Pediatric BLS Updates
• Pediatric ALS Updates
Why Do Guidelines Exist?
How Does the AHA Build the
Guidelines? • Important to review the AHA’s process
• Subject topics broken down into task forces
– Example – BLS, ALS, Acute Coronary – Example – BLS, ALS, Acute Coronary
Syndrome, Pedi ALS, NALS, Stroke, First Aid,
and Education and Implementation
• At the END of the 2005 update, each task force generated a list of unanswered questions
Evidence Experts
• These questions based on knowledge gaps from the last update
– Questions left unanswered in the literature or
with poor evidence surrounding the topicwith poor evidence surrounding the topic
• The Task Forces assigned each question
to a “Evidence Expert”
– Each question assigned to 2 evidence experts
who independently searched the literature
Review Process
• These evidence experts presented their preliminary findings to the Task Forces
– When discrepancy between the 2 experts,
they were asked to reconcile the disparity they were asked to reconcile the disparity
• All evidence presented to the Task Forces
who in turn created “Task Force Consensus on Science and Treatment
Recommendations”
Consensus on Science
Conference• These Task Force Consensus Statements
presented at a major international conference early in 2010 and vetted at that timetime
• After the conference and vetting process a writing group compiles all the Task Force recommendations, accepted comments and amendments and created an international consensus statement
AHA Process
• The AHA is part of the entire process
• Built their recommendations from the process and the final product of the international conferenceinternational conference
Remember…
• These recommendations represent the best data we have available at this time
• The science of resuscitation medicine is changing rapidly and future updates will changing rapidly and future updates will represent those changes
• Some answers we do not have yet and the AHA tries to offer the best fair and balanced input in those situations
On To the Topics…
• Adult BLS
• Adult ALS
• Pediatric ALS
• Pediatric BLS• Pediatric BLS
• Briefly touch on Post Resuscitation Care
Adult BLSAdult BLS
Adult Basic Life Support
• 2010 AHA Guidelines emphasize the importance of high-quality chest compressions including– A rate of at least 100/min (changed from – A rate of at least 100/min (changed from
approximately 100/min)
– A compression depth of at least 2 inches in adults
– Allowing for complete recoil after each compression
– Minimizing interruptions in chest compressions
– Avoiding excessive ventilations
A Word on Compressions…
• Over the last 2 AHA Updates, we have seen increasing attention directed toward chest compressions
• In 2010, chest compressions gained • In 2010, chest compressions gained enough attention that the trusted EMS A/B/C mantra was changed to C/A/B
– Purpose: To reduce delay in chest
compressions
What Saves Lives in Cardiac
Arrest? • Despite being able to bring many
advanced therapies to the patient suffering cardiac arrest the therapies that save lives are:are:
– Early defibrillation
– Chest compressions
• Medications and advanced airways DO NOT improve survival…
The Most Important Treatment
You Offer…• … is effective chest compressions
• Effective means:– Right rate (at least 100)
– Right depth (2.5 inches or 5 cm)– Right depth (2.5 inches or 5 cm)
– Relax – allow for recoil
– NO interruptions
– Avoid excessive ventilations
• Despite our best ALS capabilities, our BLS skills are what appears to be most important
Rescuer Fatigue
• We probably fatigue while doing chest compressions much sooner than we admit
• Best way to check for fatigue is to look for decreases in End Tidal CO2 while decreases in End Tidal CO2 while monitoring the patient
• AHA currently suggests that, if the personnel are available, to rotate chest compressors every 2 minutes to reduce fatigue
A Word on Ventilations….
What is Wrong With Extra
Ventilations? • Most recent changes attempted to
highlight the importance of uninterrupted chest compressions and limited the positive pressure ventilation rate to 8 – 10 positive pressure ventilation rate to 8 – 10 breaths per minute
• Why focus on minimally interrupted chest compressions and limiting positive pressure ventilation?
Minimizing Positive Pressure
Ventilation• Old Paradigm:
– ABC’s – M2M/BVM/ETT to deliver high flow O2
• New Concepts:– Positive pressure ventilation increases intrathoracic – Positive pressure ventilation increases intrathoracic
pressure
– Increased intrathoracic pressure decreases venous
return
– Resultant decrease in coronary and cerebral blood flow
• SO… AHA has recommended RR of 8 – 12 breaths/minute
But What About the Airway and
breathing? Part 1• Much smaller amounts of ventilation are
needed:
– Immediately after arrest, aortic O2 and CO2
concentrations are similar to the pre-arrest concentrations are similar to the pre-arrest
state
• There exists no blood flow and oxygen
consumption is minimal
But What About the Airway and
breathing? Part 2 – Lungs act as an oxygen reservoir for the
much reduced pulmonary blood flow
• Under BEST practices – pulmonary blood flow
during CPR is 10-15% of pulmonary blood flow
during NSRduring NSR
– Substantial ventilation occurs due to passive
movement during compression and expansion
during CPR
PULSE CHECKS?
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Just In Time Training
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Hands Only CPR
Total Number of Compressions:
At Least 100
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One Way to Remember This…
Other Songs…
ABBA Dancing Queen
All American Rejects Gives You Hell
Arrested Development Tennessee
Backstreet Boys Quit Playing Games (With My Heart)
Bangles Walk Like An Egyptian
Beastie Boys Body Movin’ [Fatboy Slim Remix]
Beastie Boys Heart Attack Man
Beastie Boys Root Down
Black Crowes Hard To Handle
Linkin Park Breaking the Habit
Ludacris The Potion
Madonna Who’s That Girl
Mariah Carey Heartbreaker
Marvin Gaye What’s Going On
Michael Jackson Man In The Mirror
Missy Elliott Work It
Motley Crue Kickstart My Heart
Notorious B.I.G. Notorious B.I.G. [Featuring Lil’ Kim and Puff Daddy]
Patty Loveless Strong HeartBlack Crowes Hard To Handle
Black Eyed Peas Hey Mama
Bon Jovi Lay Your Hands On Me
Cyndi Lauper Girls Just Want To Have Fun
Diana Ross Ain’t No Mountain High Enough
Fall Out Boy This Ain’t A Scene, It’s An Arms Race
Guns N’ Roses Paradise City
Hanson Mmmbop
John Denver Thank God I’m A Country Boy
Justin Timberlake Rock Your Body
KT Tunstall Suddenly I See
Lily Allen LDN
Patty Loveless Strong Heart
Paul Oakenfold Starry Eyed Surprise
Phil Collins You Can’t Hurry Love
Ricky Martin Shake Your Bon Bon
Rod Stewart You’re In My Heart
Shakira Hips Don’t Lie [Featuring Wyclef Jean]
Simon & Garfunkel Cecilia
Soul II Soul Back To Life
Stray Cats Rock This Town
Sugar Ray Fly
Tracy Chapman Fast Car
U2 I Still Haven’t Found What I’m Looking For
No ROUTINE Cricoid Pressure
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CPR or AED First?
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AED’s and Infants
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Mechanical CPR
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Impedance Threshold Device
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Piston Device
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Load Distributing Band
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Teamwork and ICS
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Advanced Cardiac Life Support
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Major Changes
• Algorithm Changes
• Medication Changes
• Endorsement of Capnography
• Importance of “Systems of Care” and diligent approach to the patient with return of spontaneous circulation (ROSC)
Four Major ALS Algorithms
• Universal Algorithm
• Adult Pulseless Arrest
• Bradycardia
• Tachycardia • Tachycardia
Atropine Removed from the
Pulseless Arrest Algorithm
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Adenosine
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ALSCapnography
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1. Capnography has been used to
prognosticate outcome in cardiac arrest
patients using this principle
– ETCO2 of 10 or less after 20 minutes of ACLS – ETCO2 of 10 or less after 20 minutes of ACLS
successfully discriminated between survivors and
nonsurvivors
2. Capnography helps in the evaluation of CPR
compressions
– Should see increases in ETCO2 with effective CPR
and decreases if effectiveness declines
1. Increases in ETCO2 are also the first indictor in ROSC
– During CPR, sudden increases in ETCO2 are
early indicators of ROSCearly indicators of ROSC
2. In the post-arrest or critical patient, ETCO2 and Capnography may herald loss of circulation
– In the previously stabilized patient, sudden drops
in ETCO2 should prompt the rescuer to
reinitiating CPR
• Capnography is one of the tools helpful in confirming intubation
– Expect to see a normal or near normal
ETCO2 and waveforms within a few breathsETCO2 and waveforms within a few breaths
• More importantly, Capnography is the only tool that allows ongoing live-time evaluation of ETT placement
The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide
monitoring on the rate of unrecognized misplaced intubation within a regional
emergency medical services system.
Ann Emerg Med May 2005
RESULTS:
• Two hundred forty-eight patients received out-of-hospital airway management, of whom 153 received intubation.
– Of the 153 patients, 93 (61%) had continuous ETCO2 monitoring, and 60 (39%) did not.
– Forty-nine (32%) were medical patients, 104 (68%) were trauma patients, and 51 (33%) were in cardiac arrest.
• The overall incidence of unrecognized misplaced intubations was 9%. • The overall incidence of unrecognized misplaced intubations was 9%. – The rate of unrecognized misplaced intubations in the group for whom continuous ETCO2
monitoring was used was zero, and the rate in the group for whom continuous ETCO2 monitoring was not used was 23.3%
CONCLUSION:
• No unrecognized misplaced intubations were found in patients for whom paramedics used continuous ETCO2 monitoring. Failure to use continuous ETCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.
• In cases on normal intubation with sudden loss
of tube placement, the capnogram will appear
normal (when the tube is properly placed) and
will then go flat
• Similar to the patient who becomes apnic
• In cases with little to no CO2 in the stomach, the
ETCO2 will be zero and the capnogram will be
flat or will have very low and irregular amplitude
• There are 2 conditions in which you may transiently see
a capnogram after esophageal intubation and
carbonated beverages in the stomach is one of these
conditions
• Will see bizarre wave form with goes flat within 6 breaths• Will see bizarre wave form with goes flat within 6 breaths
• Occasionally, enough alveolar gas and CO2 can
be forced into the stomach during bagging that
the capnogram will transiently appear normal
• Within 10 breaths, this CO2 washes out and the • Within 10 breaths, this CO2 washes out and the
amplitude decreases, eventually zeroing
Termination of Resuscitation
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