Taking the Team to the Next Level. Disclosure

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Gwenda Meagan Hardy
5 years ago
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1 Taking the Team to the Next Level Walt Lubbers, MD University of Kentucky Emergency Medicien Disclosure None 1

2 This is not ACLS This is not anti-acls 2

3 We don't rise to the level of our exp 3

4 This is not E-CPR or Reboa CPR Or Heads Up CPR Or 4 limb tourniquets 1. All resuscitations are goal driven 4

start IV IV bolus insert SGA compressions hand position for compressions get in position for compressions pads on patient hook bag to O2 BVM defib on charge defib OPA/ NPA deliver shock place CPR

5 start IV IV bolus insert SGA compressions hand position for compressions get in position for compressions pads on patient hook bag to O2 BVM defib on charge defib OPA/ NPA deliver shock place CPR board Identify arrest get help/ call code assign roles deliver shock next compressor in position ETCO2 on BVM mask position auscultate breath sounds feel for pulse analyze rhythm move patient draw blood fingerstick glucose stop compressions move out of the way call for shock get something to write on talk to family HPI review causes of arrest monitor ETCO2 open code cart draw up epi get drugs out push epi push amio push lidocaine push HCO3 push calcium push Mg push glucose hook up IV tubing place chest tube needle decompress head to toe exam keep time get stool review record prepare SGA prepare ETT prepare laryngoscope insert laryngoscope into mouth insert ET tube BURP maneuver insert OG/ NG limb tourniquet 5

6 0 4 min 6

8 start IV IV bolus insert SGA compressions hand position for compressions get in position for compressions pads on patient hook bag to O2 BVM defib on charge defib OPA/ NPA deliver shock place CPR board Identify arrest get help/ call code assign roles deliver shock next compressor in position ETCO2 on BVM mask position auscultate breath sounds feel for pulse analyze rhythm move patient draw blood fingerstick glucose stop compressions move out of the way call for shock get something to write on talk to family HPI review causes of arrest monitor ETCO2 open code cart draw up epi get drugs out push epi push amio push lidocaine push HCO3 push calcium push Mg push glucose hook up IV tubing place chest tube needle decompress head to toe exam keep time get stool review record prepare SGA prepare ETT prepare laryngoscope insert laryngoscope into mouth insert ET tube BURP maneuver insert OG/ NG limb tourniquet delayed PPV delayed PPV immediate PPV immediate PPV 0 Survival CPC 1-2 8

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12 2. Reformat your team 12

13 Nurse Led Code 13

14 I THOUGHTI D LET THE NURSES HANDLE THIS ONE. THEY LOOKED BORED. 14

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16 Sets goals Makes goals happen Gets stuff Doc: sets goals Does doctor stuff Nurse TL: makes things happen 16

17 Nurse TL: makes things happen Doc: sets goals Does doctor stuff Access Monitor Compressions Other doctor stuff 17

18 3. Start sweating the small stuff 18

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20 Compression Rate Compression Depth Chest Wall Recoil Ventilation Rate Chest Compression Fraction Peri-shock Interval > 80% CCF 20

21 A B C 109 SECONDS P TO 8 MINUTES 21

22 FIX: Ignore it 22

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24 Bag And if you can t bag, bag better 24

25 Survival Based on Airway Type 20 % Neuro Intact Survival SGA ETI BVM McMullan et al 2014 r a reason to stop for a Unless the airway got you into this 25

26 10-15 SECONDS EACH TIME! 30:2 26

$chest compression fraction$

27 120 compressions/ minute 30 compressions = 15 seconds 2 BVM breaths = 10 seconds 60% chest compression fraction 27

28 120 compressions/ minute First 10 comp = 5 sec (priming) 20 compressions = 10 seconds 2 BVM breaths = 10 seconds 40% perfusing CCF 28

29 FIX: 29

30 30

31 What s 30:2 based on? 31

32 30:2 means only 120 compressions/ minute 48 perfusing compressions/min First 10 comp = 5 sec (priming) CCC = 110 perfusing compressions/min 20 compressions = 10 seconds 2 BVM breaths = 10 seconds -Switch to CCC after AA is in place -Only difference is esoph ventilation 40% perfusing CCF -30:2 is hard to do Continuous Interrupted ROSC Survival Neuro intact

33 WAIT! 33

Continuous Interrupted CCF 0.83 0.77 Pauses > 2 sec 3.

34 Continuous Interrupted CCF Pauses > 2 sec Pre-shock pause Post-shock pause 6 6 Intubated 48% 49% Avg 18 sec/ min for shock= 70% CCF 34

35 Nearly CCC no CCC better are than awesome! 30:2 35

36 Continuous Interrupted CCF Pauses > 2 sec Pre-shock pause Post-shock pause 6 6 Intubated 48% 49% 22 SECONDS EACH TIME! 36

37 X YOUR PULSE CHECK 37

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notification/ say Pulse CHECK stop cpr stabilize compressor hands off patient look at monitor analyze rhythm command pulse check recognize rhythm verbalize rhythm pulse check: fingers on patient move

39 notification/ say Pulse CHECK stop cpr stabilize compressor hands off patient look at monitor analyze rhythm command pulse check recognize rhythm verbalize rhythm pulse check: fingers on patient move fingers feel pulse recognize pulse verbalize pulse command shock deliver shock charge defibrilator Clear patient push button shock delivered first compressor moves new compressor takes place new compressor hands on begin compressions 39

40 In this world, nothing can be said to be certain, except death and taxes and a pulse check every 2 minutes 30 seconds 10 seconds Time 40

41 30 seconds NEXT! 41

42 10 seconds NEXT 42

43 TIME PULSE CHECK! 43

44 PULSE CHECK! 44

45 PULSE CHECK! RHYTHM CHECK! 45

46 TEXT TEXT 46

47 TEXT 47

48 Goal Driven Resuscitation Resuscitation Command System Perfect CCF, perishock interval Monitor the patient 4. Monitor and feedback 48

49 ACLS algorithm Lives or dies Patient 49

50 isimulate art line tracing 50

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54 where did 30:2 come from 54

Basic Life Support Adult

1/3.4.1 Version 4, 03/2016 Basic Life Support Adult CFR - A EFR Collapse Initiate mobilisation of 3 to 4 practitioners / responders Unresponsive and breathing abnormally or gasping 112 / 999 Go to Primary