2016 CT STATE EMS PROTOCOLCCR/CPR UPDATE

Change to CPR/CCR

• Emphasis on:– Starting compressions sooner– Minimally interrupted compressions– High performance CPR

Change to CPR/CCR

• No more 30:2 for Adults– Pediatric – follow standard AHA CPR

• Instead:– Cycles of 2 minutes uninterrupted compressions– Check rhythm every 2 minutes– Ventilate every 10th compression on the upstroke• Do not interrupt compressions to ventilate• Don’t overventilate – will cause gastric distention• Consider using pediatric BVM

CCR

• CCR still for first 8 minutes in presumed cardiac etiology– NOT for respiratory arrest, opiate OD, pediatrics, or

trauma– Passive ventilation with OPA and NRB will usually be

used at first– May transition to active ventilations once sufficient

personnel/resources are present• This could be immediate, at 2 minutes, 8 minutes or any

point in between

No More “20 Minute Then Transport”

• Resuscitation performed on scene until ROSC or termination of efforts EXCEPT for ‘special circumstances’– “Special Circumstances” not well defined in protocol but think “can the hospital

do something to fix this that I can’t?” Ex:• Hypothermia (central rewarming)• Pulmonary embolism (lytics, ECMO, IR)• Pregnancy with potentially viable fetus (perimortem c-section)• Etc.

• Still AT LEAST 20 minutes ALS resuscitation before considering termination– Definitively manage airway prior to termination– Should continue resuscitation if ROSC is likely such as in cases with:

• Witnessed arrest and early CPR• Reversible cause• etCO2 >15mmHg• Persistent vfib/v-tach• Etc.

Changes to ALS Arrest Management

• Antiarrhythmics now “per AHA ACLS guidelines”• Medics should use etCO2 with BLS and ALS airway to

assess CPR quality and for signs of ROSC• Bicarb indications (now 2 mEQ/kg IV)

– Suspected excited delerium • New indication – that patient you were restraining who isn’t breathing

any more…– Suspected pre-existing metabolic acidosis– Known tricyclic OD (tox protocol also includes other Na channel

blockers such as cocaine and Benadryl)– Should insert an advanced airway before bicarb

• Bicarb works by creating CO2• May be harmful in a ‘closed system’ (i.e. ineffective ventilations)

Team Focused CPR

• Send a rescuer in ahead (with just gloves) to start compressions

• Pre-defined roles and positions– Different ways to set this up depending on resources– Goal is efficiency

• The example described in the protocols follows but may be adapted– Protocol example assumes at least 4 ALS providers on

scene– Strive for multiple ALS providers to fill roles– ALS provider may need to fill multiple roles

Team Focused CPR

Team Focused CPR

Team Focused CPRCompressor #1 and #2

• One on each side of chest – May be new to most but can really help– One starts compressions, the other applies

AED/Defibrilator– Seamlessly alternate (every one minute mid-cycle or

every 2 minutes) to avoid fatigue– ‘Hover’ hands during interruptions– Pre-charge manual defib before analysis– Assist with mask seal/ventilation when not

compressing

Team Focused CPRAirway and Vascular

• Airway (at patient’s head)– Inserts OPA, applies NRB– 2 handed BVM mask seal – off-cycle compressor or

airway assistant squeezes bag– Inserts advanced airway after 8 minutes– May have 2nd “airway assistant”

• Vascular/Meds– Just like the name implies– Stays out of the ‘CPR triangle’

Team Focused CPR Team Leader

• Most of us use this already but– Clear job responsibilities help to maintain consistency

and high performance in the resuscitation• Job assignment:– Coaches CPR metrics– Calls for compressor change every minute– Calls for rhythm analysis every 2 minutes and immediate

shock if indicated– Monitor CPR quality (depth, rate, interruption) and use

of metronome (100-120 bpm)– May have to do other tasks (e.g. Airway or Vascular)

Team Focused CPR Code Commander

• Ideally highest level provider– May have to do double duty as team leader

• Coordinates patient treatment decisions– Can interface with OLMC without disruption to

resuscitation• Communicates with family/loved ones– Essential, especially if termination will be

considered• Completes CPR Checklist (new to most)

CPR Checklist Example Code Commander and pit crew roles defined Chest compression interruptions minimized Compressors rotated minimum every 2 minutes Metronome set between 100-120 bpm AED/Defib applied O2 flowing and attached to NRB/BVM EtCO2 waveform present IV/IO access established Possible causes considered Gastric insufflation limited and gastric decompression

considered Family present and ongoing communication provided

Pit Crew CPR

• https://youtu.be/RNiNKluuIqE?t=25s

Mechanical CPR

• 2015 AHA Evidence review: – 2 large RCTs compared the use of LUCAS against manual

compressions for patients with OHCA– Together enrolled 7060 patients– Neither demonstrated a benefit for mechanical CPR over

manual CPR with respect to early (4-hour) and late (1- and 6-month) survival

– The PARAMEDIC study demonstrated a negative association between mechanical chest compressions and survival with good neurologic outcome (Cerebral Performance Category 1–2) at 3 months as compared with manual compressions

Mechanical CPR• 2015 AHA Recommendation:

– “The evidence does not demonstrate a benefit with the use of mechanical piston devices for chest compressions versus manual chest compressions in patients with cardiac arrest.”

– “Mechanical piston devices may be considered in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous provided that rescuers strictly limit interruptions in CPR during deployment and removal of the devices.” Ex:• Limited rescuers available• Prolonged CPR• During hypothermic cardiac arrest• In a moving ambulance• In the angiography suite• During preparation for extracorporeal CPR [ECPR]),

Mechanical CPR

• Hartford Hospital Expectations if using mechanical CPR:– Apply only after first 8 minutes manual CPR– At least yearly training and competency evaluation– MUST be able to reliably apply with less than 5

second (at most 10 second) interruptions in CPR• Time this in training; Team leader watch for this in real life

– Discontinue and revert to manual CPR if device or application problems occur

Questions?