18% Survival from In-Hospital Cardiac Arrest Ways we can do better! National Teaching Institute Denver, CO Class Code: 149 A

Size: px

Start display at page:

Download "18% Survival from In-Hospital Cardiac Arrest Ways we can do better! National Teaching Institute Denver, CO Class Code: 149 A"

Juniper Scott
5 years ago
Views:

1 18% Survival from In-Hospital Cardiac Arrest Ways we can do better! National Teaching Institute Denver, CO Class Code: 149 A Nicole Kupchik RN, MN, CCNS, CCRN, PCCN Independent CNS/Staff Nurse

2 Objectives Discuss the American Heart Association inhospital cardiac arrest consensus statement. Describe feedback devices such as waveform capnography, diastolic pressure readings, CPR performance feedback devices that can be used intra-arrest to evaluate the quality of chest compressions. Discuss ways to download data from defibrillators to provide feedback to staff on CPR quality and pre-post defibrillation pauses.

3 2010 AHA ACLS Guidelines Bigger emphasis on compressions Early defibrillation Waveform Capnography Post resuscitation algorithm New guidelines in 2015

5 In-Hospital Consensus Recommendations May 2013

6 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.

7 Most common type of In-Hospital arrest? V-fib / Pulseless VT Asystole PEA

8 AHA - GWTG Asystole & PEA make up 67% of all adult In-Hospital cardiac arrests Circulation (2013); Morrison, et al.

9 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!!!

10 Use Early High of Defibrillation waveform quality compressions capnography Amiodorone & Epi LOE IIb/ A Perform CC while getting defib ready Placing the crash cart outside of the room to ward off evil spirits!

11 #1 CPR Quality

12 Circulation Cardiovascular Quality & Outcomes 2013; 6;

13 Rate of Compressions Meta-Analysis Circulation Cardiovascular Quality & Outcomes 2013; 6;

14 Is Faster Better? Survival favored chest compression rates between 85 to 110 cpm Circulation Cardiovascular Quality & Outcomes 2013; 6;

15 A1 A2 95% CI Circulation (2012) Jun 19;125(24):

16 Slide 15 A1 Circulation Jun 19;125(24): Author, 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

17 Compression Fraction The amount of time spent providing compressions May also be called compression ratio Goal: At least 80%!

$Start 40-50% End An increased chest compression fraction is independently predictive of better survival in$

18 Chest Compression Fraction? Start 40-50% End An increased chest compression fraction is independently predictive of better survival in patients who experience a pre-hospital ventricular fibrillation/tachycardia cardiac arrest.

19 Christenson et al. Circulation (2009)

20 Disco Lives!!! 5 Medical students & 10 MDs With beat avg. 103 /minute 5 weeks later repeated Use a metronome!!!

21 Chest compressions with metronome

22 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 (5)

23 Position of the compressor What s most effective? Standing on a stepstool Kneeling on the bed Standing on the floor Jones & Lee; AJCC (5)

24 Prevent leaning!!! What are the issues with leaning?

25 Waveform Capnography Used as a marker of perfusion Normal is mmhg Goal with compressions is at least 10 mmhg Will see increase with ROSC

26 Waveform Capnography Attaches to ET tube, measures CO2

Intra-arrest Quality marker of compressions Information helpful

27 When to use Waveform Capnography When an endotracheal tube is placed Gold standard for endotracheal tube placement Intra-arrest Quality marker of compressions Information helpful to determine cessation of resuscitation efforts esp. in asystole Post arrest

28 Rate of ventilations: If patient does not have an advanced airway: 30:2 If the patient has an advanced airway: 8-10 breaths / min AHA Guidelines

29 Other adjuncts Coronary Perfusion Pressure (CPP) Diastolic pressure Goal > 20 mmhg Central venous saturation ScvO 2 normal 60 80% Goal > 30% If < 30%, assess quality of compressions

30 #2 Defibrillation

31 Biphasic energy More effectively depolarizes the heart Energy travels bi-directional Less energy needed Calculated impedance

32 Pad placement Anterior posterior Anterior lateral Skin prep: Clean skin Remove excess hair Special considerations: Bariatric Large breasts Burns Pediatrics

33 Minimize Pre & Post Shock pauses Pre Shock pause < 3 seconds Sell et al 2010 Resuscitation Post Shock pause < 6 seconds

34 AEDs in non-critical care areas 439 patients evaluated in non-monitored areas: 73 with VT/VF: 63 (86%) ROSC; 34 (47%) discharged from hospital

36 #3 Post-Arrest

37 Temperature Management Decrease temperature to degrees C for 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

38 #4 Feedback

39 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

40 Intra-arrest review: Compression fraction Goal: at least 80%!

41 Intra-Arrest Data Report 1 Second Vfib No Shock, but stopped to assess? Vfib No Shock, but stopped to assess?

42 Issues here? 17 second pause

43 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 = ECG green = impedance

44 #5 Measure, Practice & Improve

45 Response teams Dedicated team with defined, clear roles Practice, practice, practice! Team Debriefing

46 The Code Team & Defined Roles

47 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 Class code 149A

Improving Outcome from In-Hospital Cardiac Arrest

Improving Outcome from In-Hospital Cardiac Arrest National Teaching Institute San Diego, CA Nicole Kupchik RN, MN, CCNS, CCRN, PCCN, CMC Independent CNS/Staff Nurse Objectives 1. Discuss the AHA in-hospital