Hospimedica.rui n t r O d u c t i O nDebriefing has been shown to improve clinical behavior during cardiac resuscitation and, as such, has become a recommended procedure in the 2010 European Resuscitation Council Guidelines for Resuscitation. Edelson and colleagues reported that the number of patients achieving return of spontaneous circulation (ROSC) at a university hospital in the Midwest of the US increased from 44.6% to 59.4% (p=.03) when weekly debriefing sessions were conducted.1 This guide has been developed to provide guidelines for debriefing the key measures of care that can have a significant impact on outcomes from sudden cardiac arrest (SCA). The key components of an optimal in-hospital cardiac In-hospital resuscitation can be generally characterized arrest response: as a disorganized, stressful event that lacks definitive 1. Early recognition that the patient is deteriorating or leadership. Inexperienced providers and crowds of has become unresponsive.
observers are also common, as are poor outcomes. Because on average, just 17% of all in-hospital arrests 2. Bystander response. At the risk of overstating the result in survival to discharge, one wonders if the low rate issue, with the exception of the Emergency Department of survival is due to the process or the patient. Since the (ED) or critical care staff, the first responder in a hospital release of the 2005 ERC Guidelines, where emphasis is rarely more experienced than an educated bystander was placed for the first time on high-quality CPR with who comes upon a sudden cardiac arrest victim longer periods of compression and fewer ventilations, outside of the hospital. It is important that all staff are we have begun to deconstruct the response to in-hospital empowered to act, even if that means doing nothing cardiac arrest. Early data indicate that survival from more than immediately starting high-quality CPR. At a in-hospital cardiac arrest can be improved (i.e., the minimum, the second responder should bring the crash current low rate of survival from in-hospital arrest cannot cart to the room, deploy the defibrillator pads, and turn be entirely attributed to unsalvageable patients). It has on the defibrillator in anticipation of the arrival of the become evident that obtaining a good outcome requires medical emergency team. a chain of events, and in the dead center of the chain is the in-hospital cardiac arrest response. 1 Edelson DP, et al. Arch Intern Med. 2008;168(10):1063–69.
3. Early defibrillation when indicated. In the hospital, 4. High-quality, minimally interrupted CPR. the arrhythmic arrest that requires an immediate Studies continue to show that high-quality CPR can make diagnosis and shock is generally confined to the cardiac the difference between survival and death.5,6,7 care unit, surgical intensive care unit, ED, or telemetry. The vast majority of resuscitations outside of these units The 2010 Guidelines state that the use of CPR feedback result from respiratory failure, and the need for a rapid tools should be considered in both mock codes and defibrillation response may be less important than in actual rescues. Data generated by Peberdy, et al. immediate circulatory support. show how feedback can support the performance of compressions in target - individual compressions In 2010 there were two lower-level studies available delivered at the correct depth and rate, according to comparing the use of AEDs in adults with in-hospital Guideline recommendations.8 In a manikin study of cardiac arrest with shockable rhythms versus manual 125 health care professionals, compressions in target defibrillators. Both studies showed higher survival-to- averaged 15% without feedback and 78% when hospital discharge rates if defibrillation was provided audiovisual feedback on compression depth and rate through an AED program than with manual defibrillation alone2,3. AEDs are a good alternative to facilitate early in-hospital defibrillation (goal of <3 min from collapse)4, The importance of short pauses for pulse checks, pre-shock especially in those areas where healthcare providers and post-shock was demonstrated by Edelson et al 9; the have no or limited rhythm recognition skills or where shock success rate was 94% when a shock was delivered they use defibrillators infrequent. Key is to support the within 10 seconds after stopping CPR but dwindled to AED program with an effective training and retraining 38% with a 30-second pause. program. Enough healthcare providers should be trained to enable the first system shock to be given within 3 min The total amount of time in CPR is also critical for a of collapse anywhere in the hospital. Hospitals should successful outcome. The CPR fraction, defined as the monitor collapse-to-first shock intervals and monitor/ percentage of time that compressions are delivered debrief resuscitation outcomes.
during a code, is an important measure of CPR Rapid recognition of a shockable rhythm and immediate shock delivery is critical when the presenting rhythm is coarse ventricular fibrillation (VF) or ventricular tachycardia (VT) because delays in shock delivery reduce shock efficacy. Inadvertent shocking of fine VF should be avoided as inappropriate shocks can result in asystole - a rhythm that is difficult to convert to a perfusing rhythm. 2 Zafari AM, et al. A program encouraging early defibrillation results in improved in-hospital 6 Bohn A, et al. Anaesthesist. 2011;60(7):653–660. resuscitation efficacy. J Am Coll Cardiol 2004;44:846–52.
7 Davis DP, et al. Abstract presented at the 2009 ReSS symposium of the AHA. 3 Destro A, et al. Automatic external defibrillators in the hospital as well? Resuscitation. 8 Peberdy MA, et al. Resuscitation. 2009;80:1169–1174. 9 Edelson DP, et al. Resuscitation. 2006;71:137-145 4 Chan P, et al. Arch Intern Med. 2009;169(14)1265–73.
5 Abella BS, et al. Circulation. 2005;111:428–34.
While a CPR fraction of 50% to 60% is typical, this 6. Appropriate use of drugs and auxiliary equipment. is not acceptable to achieve good patient outcome. Based on expert consensus the ERC Guidelines suggest, After implementing an Advanced Resuscitation Training for VF/VT to give adrenaline after the third shock once (ART) program at the University of California San Diego chest compressions have resumed, and then to repeat (UCSD) Medical Center, that emphasizes minimizing every 3–5 min during cardiac arrest (alternate cycles)13. chest compression interruption, UCSD Resuscitation Director Daniel Davis, MD, reported a 91% CPR fraction Amiodarone 300mg is also given after the third shock. and a doubling of survival to discharge at UCSD CPR should not be interrupted to administer drugs13.
The Guidelines suggest that use of intraosseous 5. Controlled ventilation. Aufderheide, et al. cannulation may speed vascular access, and use of demonstrated that excessive ventilation (20 to 30 laryngeal airways may aid in rapid intubation. times a minute) causes intrathoracic pressure to rise, Transcutaneous pacing is currently only recommended impeding cardiac filling and reducing coronary perfusion to treat bradycardia, not asystole. pressure10. Edelson demonstrated that the use of end-tidal CO2 was the most accurate means to track respirations 7. Consider the reversible causes of arrest. At some during a code.11 The 2010 ERC Guidelines recommend point in the resuscitation, time should be taken to rapidly the use of EtCO2 for intubation verification and for assess whether the patient may have a reversible cause tracking of the resuscitation progress12. According to the of arrest, such as the Hs and Ts: current Guidelines, ventilation should be performed at a • Hypovolemia, hypoxia, hydrogen ions (acidosis), rate of 2 ventilations for every 30 compressions before hyperkalemia or hypokalemia, hypothermia, intubation, and 8 to 10 times a minute after intubation. hyperglycemia and hypoglycemia • Toxins, tamponade, tension pneumothorax, Ideally, intubation should be performed without pausing thrombosis, thromboembolism, trauma compressions, or done during other natural pauses (for rhythm analysis or pulse checks). Delays in intubation A checklist of signs and symptoms can be helpful. and multiple attempts should be noted. 10 Davis DP. CEU program, A New Algorithm for CPR Training: Strengthening the 12 Edelson DP, et al. Resuscitation. 2010;81:317–322. Chain of Survival. Medcom Trainex. 2012 13 2010 European Resuscitation Council Guidelines for Resuscitation. Resuscitation. 81 (2010) 11 Aufderheide TP, et al. Circulation. 2004 Apr 27;109(16):1960—5.
The charts below show the ERC Adult Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) algorithms as well as the pediatric and newborn resuscitation algorithms. Adult Basic Life Support - BLS Resuscitation, 81 (2010) 1219-1276 Copyright European Resuscitation Council www.erc.edu 2013/024
Advanced Life Support CPR Quality
• Push hard (=2 inches [5 cm]) and fast (=100/min) and allow complete chest recoil Minimize interruptions in • Avoid excessive ventilation • Rotate compressor every 2 • If no advanced airway, 30:2 compression-ventilation ratio • Quantitative waveform • If PETCO2 <10 mm Hg, attempt to improve CPR quality Intra-arterial pressure • If relaxation phase (diastolic) pressure<20 mm Hg, attempt to improve CPR quality Return of Spontaneous
Pulse and blood pressure • Abrupt sustained increase in PETCO2 (typically =40 mm Hg) • Spontaneous arterial pressure waves with intra-arterial Shock Energy
• Biphasic: Manufacturer
recommendation (120-200 J); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered. • Monophasic: 360 J
• Adrenaline IV/IO Dose:
1 mg after the third shock repeat every 3-5 minutes • Amiodarone IV/IO Dose:
First dose: 300 mg bolus. Second dose: 150 mg. Advanced Airway
• Supraglottic advanced airway or endotracheal intubation • Waveform capnography to confirm and monitor ET tube • 8-10 breaths per minute with continuous chest compressions Resuscitation, 81 (2010) 1219-1276 Copyright European Resuscitation Council www.erc.edu 2013/024
Pediatric Advanced Life Support CPR Quality
• Push hard (=1/3 of anterior- posterior diameter of chest) and fast (at least 100/min) and allow complete chest recoil Minimize interruptions in • Avoid excessive ventilation • Rotate compressor every 2 • If no advanced airway, 15:2 compression-ventilation ratio. If advanced airway, 8-10 breaths per minute with continuous chest compressions Shock Energy for
• First shock 4 J/kg, subsequent shocks =4 J/kg, maximum 10 J/kg or adult dose. Drug Therapy
• Adrenaline IO/IV Dose:
0.01 mg/kg (0.1 mL/kg of 1:10 000 concentration) after the third shock. Repeat every 3-5 minutes. If no IO/IV access, may give endotracheal dose: 0.1 mg/kg (0.1 mL/kg of 1:1000 • Amiodarone IO/IV Dose: 5
mg/kg bolus during cardiac arrest. May repeat up to 2 times for refractory VF/ Advanced Airway
• Endotracheal intubation or supraglottic advanced airway • Waveform capnography or capnometry to confirm and monitor ET tube placement • Once advanced airway in place give 1 breath every 6-8 seconds (8-10 breaths per Return of Spontaneous
Pulse and blood pressure • Spontaneous arterial pressure waves with intra-arterial Resuscitation, 81 (2010) 1219-1276 Copyright European Resuscitation Council www.erc.edu 2013/024
Newborn Life Support Resuscitation, 81 (2010) 1219-1276 Copyright European Resuscitation Council www.erc.edu 2013/024 ZOLL Medical Corporation • Chelmsford, MA, USA • 800-804-4356 • www.zoll.com 2013 ZOLL Medical Corporation. All rights reserved. ZOLL, RescueNet, and Code Review are registered trademarks of ZOLL Medical Corporation in the United States and/or other countries. All other trademarks are property of their respective owners.
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