Transcript The ResQ Trial: - Whatcom County EMS Council

Adult CPR and the
ResQ Trial
Prepared by
Janice Lapsansky
Spring 2006
Agenda
• Major Changes in AHA guidelines for adult CPR
• ResQ Trial overview
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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 Phone First:
–On an unresponsive adult, when collapse is most
likely cardiac in origin.
• 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
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
the unresponsive trauma victim.
• Manual stabilization of the C-spine is preferred
over mechanical devices.
Rescue Breathing
Without 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
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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
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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
ACD-CPR + ITD
Standard Treatment
•Defibrillation
• Intubation
• IV & medications
Outcome
1033 patients
per group
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)
Troubleshooting
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.
– 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-CPR
Compression
• 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-CPR
Decompression
 Lift until force gauge
reads approx.
–20 to –30 lbs
Most common error is
failure to actively
decompress chest
Troubleshooting
ACD-CPR
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Suction problems in 10-15% of patients
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May interfere with AP patch placement
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Check placement and continue
Hickey or bruising to chest
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Rotate frequently
Rib fractures
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Move patches
Requires 25% more rescuer energy
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Reposition, shave, or dry off chest
Continue use unless distracting
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.