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The Top 5 Ways to Improve Outcomes from Cardiac Arrest
Emergency Nurses AssociationIndianapolis, IN
Nicole Kupchik RN, MN, CCNS, CCRN, PCCNIndependent CNS/Staff Nurse
Objectives• Discuss the American Heart Association in-
hospital cardiac arrest consensus statement.• Describe feedback devices such as ▫ waveform capnography▫ diastolic pressure readings▫ CPR performance feedback devices
• Discuss ways to download data from defibrillators to provide feedback to staff on CPR quality and pre-post defibrillation pauses.
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2010 AHA ACLS Guidelines• Bigger emphasis on compressions• Early defibrillation• Waveform Capnography• Post resuscitation algorithm
In-Hospital Consensus Recommendations
May 2013
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According to the GWTG database, the survival rate from in-hospital cardiac arrest is:
A. 5%B. 18%C. 30%D. 50%
5% 18%
30%
50%
18%
9%
18%
55%
Chances of surviving an In-Hospital Cardiac Arrest?
Defined by ICD-9 code for Cardiac Arrest – Including those admitted through the ED with CA
Circulation (2013); Morrison, et al.
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What is the most common type of in-hospital cardiac arrest?
A. PEA & AsystoleB. Vfib & PEAC. Vtach & VfibD. Asystole & Vfib
PEA &
Asystole
Vfib & PEA
Vtach &
Vfib
Asystole & Vfib
8%
23%
38%
31%
AHA - GWTG
Asystole & PEA make up 67% of all adult In-Hospital cardiac arrests
Circulation (2013); Morrison, et al.
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What can we do to improve?• Prevent the arrest!• Resuscitate those who are resuscitatable!
#1 CPR Quality#2 Early & effective defibrillation#3 Post-Arrest temperature control#4 Feedback to teams on performance#5 Measure, practice & improve!!!
High quality
compressions
Early Defibrillation
Use of waveform
capnography
Amiodorone & Epi
LOE IIb/ A
Perform CC while getting defib ready
Hypothermia post arrest –32 – 34˚ C for 12 – 24 hours
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#1 CPR Quality
Is Faster Better?
Survival favored chest compression rates between 85 to 110 cpm
Circulation Cardiovascular Quality & Outcomes 2013; 6; 148-156
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Circulation (2012) Jun 19;125(24):3004-12
95% CI
A1A2
Compression Fraction• The amount of time spent providing
compressions• May also be called “compression ratio”
• Goal: At least 80%!
Slide 13
A1 Circulation. 2012 Jun 19;125(24):3004-12Author, 4/6/2014
A2 Adjusted cubic spline of the relationship between chest compression rates and the probability of return of spontaneous circulation (ROSC). The adjusted model includes sex, age, bystander witnessed arrest, EMS witnessed arrest, first known EMS rhythm, attempted bystander CPR, public location, and site location (y-axis). Probability of ROSC versus average chest compression rate when other covariates are equal to the population average. We used a global test, which tested the null hypothesis that the spline curve is a horizontal line (p = 0.012). A histogram of the compression rates and numbers of patients is included. Dashed lines show 95% confidence intervals.Author, 4/6/2014
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Chest Compression Fraction?
Start End40-50%
An increased chest compression fraction is independently predictive of better survival in patients who experience a pre-hospital ventricular fibrillation/tachycardia cardiac
arrest.
Christenson et al. Circulation (2009)
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Disco Lives!!!• 5 Medical students & 10 MDs• With beat of song, averaged 103 /minute• 5 weeks later repeated
Use a metronome!!!
Chest compressions with metronome
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Who provides more effective compressions?
A. MalesB. Females
Males
Females
40%
60%
Who provided more effective CPR?
• 36 RNs (26 females, 20 males)
• 80% effective compressions by males• Vs. 40% effective compressions
by females
Jones & Lee; AJCC 2008 17(5)
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What is the best position to provide compressions to a patient in a hospital bed?
A. Standing on the floor
B. Kneeling on the bed
C. Standing on a step stool
Standing on the floor
Kneeling on the bed
Standing on a step stool
0%
71%
29%
Jones & Lee; AJCC 2008 17(5)
Prevent leaning!!!
What are the issues with leaning?
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Waveform Capnography
• Used as a marker of perfusion• Normal is 35 – 40 mmHg• Goal with compressions is at least 10 mmHg• Will see increase with ROSC
Waveform Capnography
• Attaches to ET tube, measures CO2
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Other adjuncts• Coronary Perfusion Pressure (CPP)▫ Diastolic pressure▫ Goal > 20 mmHg
• Central venous saturation▫ ScvO2 – normal 60 – 80%▫ Goal > 30%▫ If < 30%, assess quality of compressions
Rate of ventilations:
• If patient does not have an advanced airway:
30:2• If the patient has an advanced airway:
8 - 10 breaths / min-2010 AHA Guidelines
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#2 Defibrillation
Ventricular fibrillation• Most successful treatment for v-fib is defibrillation!• For every minute delay, survival decreases by
10%!!!
Metoba et al (2010) Circulation N = 13, 053
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Minimize Pre & Post Shock pauses
Pre‐Shock pause
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Which of the following medications has been shown to increase survival to discharge from cardiac arrest?
A. EpinephrineB. VasopressinC. BicarbD. AmiodoroneE. None of the above
Epinephrine
Vasopressin
Bicarb
Amiodoro
ne
None of the above
9%0%
91%
0%0%
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#3 Post-Arrest
Temperature Management• Decrease temperature to 32 – 34 degrees C for
12 – 24 hours• Studied in v-fib & v-tach arrests
• New study showing 36 degrees may also be effective Nielsen (2013)
• Closely monitor hemodynamics▫ Consider using PetCO2
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#4 Feedback
AHA Consensus Recommendation
2013 Consensus Recommendation:“…resuscitation data from the defibrillator or any other
device or source documentation that captures data at the scene should be used for feedback to the team”
Circulation, 2013
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Intra-arrest review:
Compression fraction
Goal: at least 80%!
Intra-Arrest Data Report
1 Second
Vfib – No Shock, but stopped to assess?
Vfib – No Shock, but stopped to assess?
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Issues here?
17 second pause
Pre & Post Shock Pauses
2
•Pre-shock and post shock pauses lead to CPR interruptions
•24 second pre and post shock pause
•“Wasted” interruption—patient remained in VF
black = ECGgreen = impedance
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#5 Measure, Practice & Improve
Response teams• Dedicated team with defined, clear roles• Practice, practice, practice!• Team Debriefing
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The Code Team & Defined Roles
In conclusion:• Provide good quality compressions• Minimize interruptions in compression• Defibrillate early with minimal pre/post shock
pauses• Avoid over-ventilation• Practice! Give feedback on performance• Identify roles and establish clear expectations• Post-resuscitation care• Control the temperature post arrest
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