Taking the Team to the Next Level Walt Lubbers, MD University of Kentucky Emergency Medicien Disclosure None 1
This is not ACLS This is not anti-acls 2
We don't rise to the level of our exp 3
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 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
0 4 min 6
4 10 10 7
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 50 37.5 delayed PPV delayed PPV 25 12.5 immediate PPV immediate PPV 0 Survival CPC 1-2 8
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2. Reformat your team 12
Nurse Led Code 13
I THOUGHTI D LET THE NURSES HANDLE THIS ONE. THEY LOOKED BORED. 14
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Sets goals Makes goals happen Gets stuff Doc: sets goals Does doctor stuff Nurse TL: makes things happen 16
Nurse TL: makes things happen Doc: sets goals Does doctor stuff Access Monitor Compressions Other doctor stuff 17
3. Start sweating the small stuff 18
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Compression Rate Compression Depth Chest Wall Recoil Ventilation Rate Chest Compression Fraction Peri-shock Interval > 80% CCF 20
A B C 109 SECONDS P TO 8 MINUTES 21
FIX: Ignore it 22
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Bag And if you can t bag, bag better 24
Survival Based on Airway Type 20 % Neuro Intact Survival 15 10 5 0 SGA ETI BVM McMullan et al 2014 r a reason to stop for a Unless the airway got you into this 25
10-15 SECONDS EACH TIME! 30:2 26
120 compressions/ minute 30 compressions = 15 seconds 2 BVM breaths = 10 seconds 60% chest compression fraction 27
120 compressions/ minute First 10 comp = 5 sec (priming) 20 compressions = 10 seconds 2 BVM breaths = 10 seconds 40% perfusing CCF 28
FIX: 29
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What s 30:2 based on? 31
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 24.2 25.3 Survival 9.0 9.7 Neuro intact 7.0 7.7 32
WAIT! 33
Continuous Interrupted CCF 0.83 0.77 Pauses > 2 sec 3.8 7 Pre-shock pause 12 12 Post-shock pause 6 6 Intubated 48% 49% Avg 18 sec/ min for shock= 70% CCF 34
Nearly CCC no CCC better are than awesome! 30:2 35
Continuous Interrupted CCF 0.83 0.77 Pauses > 2 sec 3.8 7 Pre-shock pause 12 12 Post-shock pause 6 6 Intubated 48% 49% 22 SECONDS EACH TIME! 36
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 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
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
30 seconds NEXT! 41
10 seconds NEXT 42
TIME 1-2-3-4-5-6-7-8-9-10 PULSE CHECK! 43
PULSE CHECK! 44
PULSE CHECK! RHYTHM CHECK! 45
TEXT TEXT 46
TEXT 47
Goal Driven Resuscitation Resuscitation Command System Perfect CCF, perishock interval Monitor the patient 4. Monitor and feedback 48
ACLS algorithm Lives or dies Patient 49
isimulate art line tracing 50
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where did 30:2 come from 54