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Published bySherilyn Simmons Modified over 9 years ago
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2015 THE STATE OF RESUCITATION
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Chain of Survival Immediate Recognition Early CPR Rapid Defib Effective ALS Intergrated Post Care CAB not ABC No breathing or only gasping Pulse checks limit to ten seconds THE CPR WE KNOW AND LOVE
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Push hard push fast Lower half of the sternum Allow for full chest recoil *Rate at least 100 per minute* Depth 1/3 for Ped to at least 2 inches for adults Limit interruptions Compression One rescuer Adult-30:2 Ped (Infant and Child)-30:2 Two Rescuer Adult-30:2 Ped (Infant and Child) 15:2 COMPRESSION
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Low pressure Patients with obstructed airways or poor lung compliance may require more Chest rise Rate Adult 1 breath every 5-6 seconds Pediatric 1 breath every 3-5 seconds Asynchronous with Advanced Airway VENTILATIONS
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Collective learning Increase learning rate Business “SAVING LIVES” CHANGES & WHY THEY ARE IMPORTANT?
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Compressions Pit crew CCR Ventilations O2 ??????????? WHAT ARE THE CHANGES?
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Rate and depth Metronome Mechanical devices COMPRESSIONS
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Chest Compression fraction Time of the chest Goal 80% Rates 100-120 per minute. Depth still 2 inches and 1/3 in children Full chest recoil avoid excessive ventilations RATE AND DEPTH
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Metronome-Life Pack 15 Physio-control TFI and Zoll METRONOME AND COMPRESSION MEASUREMENT
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Piston Active Compression-Decompression ACD devices Load distributing bands Perceived benefits Final Conclusion-MFD and RAA MECHANICAL DEVICES
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Pit Crew CPR Each responder has one function Engineered to be the same Priorities are the same each time Compression-CF Defibrillation-Shock/Don’t shock, pre-charge Controlled ventilations Stay and Play not Load and Go PIT CREW CPR
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Goal=Less than 10 second break in every 2 minute cycle of CPR 30:2 100 compressions/min =18s for compressions 5 second break for ventilations every 30 compressions? 18 of every 23s in active compression is 78% NOT counting other breaks in CPR Pit Crew Continuous compressions w/asynchronous ventilation 10s break every 2 min is 92% 5s break every 2 min is 96% PIT CREW
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PIT CREW CPR
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Components 1. Continuous chest compression without ventilations 2. Deemphasizing –intubations, ventilations but emphasize CCC early defibrillation and early administrations of EPI CARDIOCEREBRAL RESUSCITATION
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Hyperventilation Resqpod Capnnometry readings VENTILATIONS
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Hyperoxia AMI-Increase systemic Vascular resistance, decrease cardiac output and stroke volume Cardiac arrest-poor neurological outcomes COPD-Austin COPD study 2% vs 9% Goal Ischemia and infarction aim for mid 90 but not 98-100 94-95% stable 89-92% COPD Avoid high flow 02 in patients with stable saturations OXYGEN
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Diffusion of 02 Decreasing intra-thoracic pressure NC during intubation or NRB during CPR PASSIVE OXYGENATION
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Resuscitations Outcomes Consortium (ROC) ETI VS SGA 8,847 patients underwent ET compared to 1,968 Neurological intact ET=4.7 and SGA=3.9 Japanese 2013 study ETI and SGA new skills BVM=2.6 times better survival Comparable to the CARES study SGA first line airway in Cardiac arrest Understanding the effects of Positive Pressure Ventilations Bottom Line-What do you do? Pre-hospital Airway management and Neurological outcomes are linked the question is why? ETI VS. SGA
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Detrimental impact Common in hospital and pre-hospital Effects Tools HYPERVENTIALTION
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What is it? “The ResQPOD is an impedance threshold device (ITD) that provides Perfusion on Demand (POD) by regulating pressures in the thorax during states of hypotension. Early studies Pirallo compared to “sham” device Improved BP in arrest victims ROC Primed-no improvement in outcomes Increased Resuscitation results when used with other Tech. RESQ-POD
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What are the reading associated with ROSC? Spontaneous increase to values between 35-45 <less than 10 ROSC unlikely AHA recommendations: Confirm placement of ET tube and monitor waveform. Monitor the adequacy of ventilation and oxygenation. Monitor CPR quality, optimize chest compression, detect ROSC if waveform capnography is less than 10mm hg improve CPR. CAPNOGRAPHY READINGS
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Sequential defibrillation Cardiac rhythm review DEFIBRILLATION
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Double defib? Last ditch effort Continuous V-tach/V-fib The science The how SEQUENTIAL DEFIBRILLATION
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Resuscitation 2014 Electrical exposure risk associated with hands-on defibrillation Study outcomes Safety of HOD not known If you do make sure you are wearing gloves Do not place hands on pads HOD or not minimize pre-shock pause Large real life study needed HANDS ON DEFIBRILATION
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Old standbys DRUGS
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Central ROLE??? Japanese study 2007-2010 2,000 v-tach and v-fib/10,000 PEA and Asystole Did receive ROSC 17 vs 13.4 % and 4 and 2.4% Poor neurological outcomes Australians study 2011 ROSC but no changes in hospital discharge Other Drugs with EPI Vasopressin and steroids Greek Study in VSE (vasopressin, steroids, epi) ROSC and hospital charge 13.9% vs 5.1% EPI
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University of Warwick Poss. published 2019? Public out cry UK STUDY
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Theureptic hypothermia Reprofusion centers AFTER CARE
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2010 AHA “ The 2010 AHA Guidelines for CPR and ECC recommends cooling comatose (i.e. lack of meaningful response to verbal commands) adult patients with ROSC after out- of-hospital VD cardiac arrest to 32 to 34 degrees for 12-24 hours. Healthcare providers should also consider induced hypothermia for comatose adult patients with ROSC after in-hospital cardiac arrest of any initial rhythm or after out-of-hospital cardiac arrest with an initial rhythm of PEA or Asystole” 2010 ACLS provider manual” Science= Decrease or suppress many of the chemical reactions that lead to cell death/Decrease Cerebral Met. Rate 2014 JAMA-Effect of Pre-hospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults with Cardiac Arrest Randomized Clinical trial Outcomes No improvement in any Neuro status group EMS group increase in re-arrest and pulmonary edema What is Not said-Should we cool or not cool to 33 C/Difference in Urban Vs. Rural.-Currently TH exact role unknown THERAPEUTIC HYPOTHERMIA
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Evidence for taking patients to centers where they can perform angiography (PCI) and hypothermia. “organized post-arrest care with an emphasis on multi- disciplinary programs that focus on optimizing hemodynamic, neurologic, and metabolic function may improve survival to hospital discharge among victims who achieve ROSC following cardiac arrest either in-or out of hospital” Jems 2012 EMS State of the Science Bypassing closer hospitals? Page 28 ACLS provider manual ECMO example from Jems REPERFUSION CENTERS
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AHA ACLS ROSC? Presence of reliable data indicating death DNR Consider other issue drug overdose and hypothermia Not every patient should be transported (P.91 Acls) Capnography >10mg Resuscitating beyond the 25 minute mark Standard in ACLS WHAT IS THE NEUROLOGICAL OUTCOME OF THESE PATEINTS? CPC values of 1 or 2 Better question is what is the point for ROSC and good neurlogical outcomes FIELD TERMINATION
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TAKE 10 is a community-focused effort to improve bystander CPR rates and thus improve survival. Learning chest compression only CPR for adults is simple. TAKE 10 is a 10 minute training session that teaches compression only CPR. GETTING THE CPR MESSAGE OUT https://www.youtube.com/watch?v=Rkryc2 5Qsm8
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Change is coming everyday whether we like it or not CPR needs to be performed flawlessly Focus on minimizing all delays i.e. charging, time off chest EPI role in arrest remains unknown O2 is not benign drug. Therapeutic hypothermia doesn’t appear to have any proven benefits it may be started at the hospital. TAKE AWAY MESSAGES
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THE END
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Example Greater Miami Valley EMS protocols for the treatment of ROSC. See handouts Ice packs/chilled fluid HYPOTHERMIA PROTOCOL
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