top 5 ways to improve ena 2014...of spontaneous circulation (rosc). the adjusted model includes sex,...

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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.


2010 AHA ACLS Guidelines• Bigger emphasis on compressions• Early defibrillation• Waveform Capnography• Post resuscitation algorithm

In-Hospital Consensus Recommendations

May 2013


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.


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.


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


#1 CPR Quality

Is Faster Better?

Survival favored chest compression rates between 85 to 110 cpm

Circulation Cardiovascular Quality & Outcomes 2013; 6; 148-156


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%!

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


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)


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


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)


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?


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


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


#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


Minimize Pre & Post Shock pauses

Pre‐Shock pause


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%


#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


#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


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?


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


#5 Measure, Practice & Improve

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


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

top 5 ways to improve ena 2014...of spontaneous circulation (rosc). the adjusted model includes sex,...

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