High-Functioning EMS CPR Teams. Sally A Taylor - Paramedic Atlantic Partners EMS
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1 High-Functioning EMS CPR Teams Cardiac Arrest Management Sally A Taylor - Paramedic Atlantic Partners EMS
2 Insanity: Doing the same thing over and over and expecting a different result. John Dryden The Spanish Friar (Act II, Scene 1) We Raise the Dead
3 We Raise the Dead This begs the question: Why do we put so much money and resources into cardiac arrest management when the out-ofhospital survival rate remains abysmally miniscule?
4 CPR is over 50 years old, but recent changes have shown increases in survival A B A. Peter Safar, 1950s B. Early symposium on CPR 1961
5 2005 AHA Guidelines
6 2010 AHA Guidelines EVEN EVEN EVEN
7 3-Phase Time-Sensitive Model of Cardiac Arrest Due to VF The Electrical Phase (0 to ~5 minutes) Early defibrillation life-saving The Circulatory Phase (~5 to ~10 minutes) Intubation and immediate AED can be detrimental Compressions first may be life saving The Metabolic Phase (~>10 minutes) Survival decreased Science searching for more successful treatments Weisfeldt ML, Becker LB. JAMA 2002;288:3035
8 Medications proven to improve outcome in cardiac arrest?
9 The priority is quality compressions Reflected in the poor impact of ACLS meds: 2009 Randomized trial of EPINEPHrine versus no EPINEPHrine For EMS treated cardiac arrest NO BENEFIT IN SURVIVAL TO DISCHARGE FROM HOSPITAL!
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11 The quality of CPR Are compression/recoil equally important? Do length/frequency of pauses matter? Is compression rate important? Does CPR improve ALS? Is there a better way? HPCPR
12 AHA 2010 Guidelines C-A-B Uninterupted chest compressions Waveform capnography Deemphasized: Intubation Drugs Mechanical CPR
13 High Performance CPR Science demonstrates that ROSC increases when CPR is performed according to guidelines. HPCPR emphasizes minimal pauses, full compression recoil, adequate compression depth and optimal compression rate. 13
14 High Performance CPR: 10 components 1. EMTs own CPR 2. Minimize interruptions in CPR at all times 3. Ensure proper compression depth (>2 inches) 4. Ensure full chest recoil 5. Ensure proper compression rate ( /min) 6. Rotate Compressors every 2 minutes 7. Hover hands over chest during shock administration and be ready to compress as soon as pt is cleared 8. Intubate or place advanced AW with ongoing CPR 9. Place IV or IO with ongoing CPR 10.Coordination and teamwork between BLS and ALS Shock CPR 14
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17 The Value of Team EMS is a Team Sport Improving CA Survival is a Team Sport
18 High-Functioning CPR Agency The Pit Crew Team
19 Equipment organized to be efficient
20 Team member roles pre-assigned
21 Frequent practice/ simulation
22 Pit Crew Approach High-functioning Team Teamwork Leadership Situational Awareness (Roles) Communication Mutual Support Role of Checklist Designed for Efficiency/ Uniformity Evidence-based Perfect practice makes perfect Initial training/ Simulation Regular practice/ Simulation
23 Pit Crew Approach The Triangle of Life
24 High-Functioning CPR Team Continuous Quality Improvement Each agency must adjust pit crew example diagram for local response: Number of responders BLS and ALS Device preferences Medical director oversight Must Measure Outcomes PDSA Cycle (Continuous Improvement) Plan Do Study Act Small Tests of Change
25 Pit Crew Approach Compressions are Priority Continuous chest compressions with minimal interruption are key USE any available feedback device/ metronome Alternate compressions between providers across patient s chest (e.g. 100 each) Chest compressions should continue when charging an AED or manual defibrillator Chest compressions should resume immediately after any shock Goal = keep interruptions for rhythm check/defibrillation < 10 seconds Goal = NO interruption for airway device insertion
26 Post-resuscitation Care Checklist Before moving patient: Augment marginal BP with IV fluid bolus and/or pressor drip Obtain 12-lead ECG if possible Titrate O2 to SpO2 between 95 99% Monitor continous ETCO2 and ventilation rate if advanced airway Mask travels with bag-valve no matter what airway is in place Package on backboard/firm surface Is transport to center capable of PCI / hypothermia possible?
27 Key take home points 1.Cardiac arrest is not hopeless! 2.CPR quality has biggest impact Adequate chest compression rate ( /min) Maximize chest compression depth (>2 in.) Allow for complete chest recoil Minimize pauses!! 3.Minimize ventilations rate & volume 4.Use capnography & debriefing, consider CPR feedback tools
28 Everybody in VF survives
29 But it s NOT EASY IT S NOT COMPLICATED
30 Questions or Comments? Thank you
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