INTRODUCTION
I was recently speaking with a colleague, about a recently published paper on ‘ideal’ compressions and depth combinations in cardiac resuscitation and I was ranting away. She asked if I would write down the things I was ranting about, as she had found them helpful. So here goes, a short list of my 11 resus do’s and dont’s. It’s my practical approach. I’m sure you have many of yours you can add.
Duval et al., recently published, a paper in JAMA Cardiology titled “Optimal Combination of Compression Rate and Depth During Cardiopulmonary Resuscitation for Functionally Favourable Survival”, the authors proposed an ideal rate and depth of cardiac compressions during out-of-hospital cardiac arrests. This was a cohort study with 3,643 patients in total. The bottom line was that they found that the most favourable combination of the rate of compression and depth to give a functionally good outcome (modified Rankin ≤3) in out-of-hospital cardiac arrests, was a rate of 107 compressions and a depth of 4.7cm.
We’ve had several studies look at each of these variables independently before, however now we’re seeing the best combination of rate and depth.
When I look at this paper, I get excited at the fact that we are now almost proposing a formula for maximal success. The formula gives us the best combination of things to do, now, our execution needs to be there. We need to practice on a regular basis and understand the weaknesses we have, an improve on them.
Here is my list of 11 things I try to do in an adult cardiac arrest resuscitation, or would want to do in a more ideal world.
1 Make Order of Chaos during the resuscitation
I, like you, have seen many cardiac resuscitations and the ones, that are the most successful, always seem to be the ones where there is order. There is a methodical, quiet, atmosphere of focused resolution in the resus cubicle. When you’ve seen these types of resuscitations run by experienced team leaders and trained, well-rehearsed team members and then walk into ones where there is almost anarchy, the difference is so obvious. The resuscitation is usually not going well and the stress of the staff is palpable.
The key is organisation, everyone has a role and knows what it is and carries it out.
2 Team Leadership is key
Someone has to take charge.
In larger institutions, this is made simple by the fact that there are designated Code Blue teams, usually ICU based. The leader is pre-determined, the staff go to the patient and coordinate everyone else.
In smaller rural centres there’s usually a smaller number of staff to run these, and the organisation has to be approached differently.
The team leader must work ‘ON’ the cardiac resuscitation, not ‘IN’ the resuscitation. Their role is to stand back, look, think, trust those in their assigned roles, but always assess and plan. They can’t be caught up putting in a line. I know that it’s easier said than done in smaller centres, but it is doable.
I recently walked into a cardiac resuscitation, that had been going for a little while. There was a retrieval doctor, anaesthetist and a medical registrar plus a whole bunch of other staff, but I couldn’t tell who was leading the resuscitation. It was a complex rests, a stressful one; aren’t they all? People were working ‘in’ the resuscitation rather than having a team leader working ‘on’ the resuscitation. Sometimes with smaller groups, that may have to happen. In my view, the team leader takes the airway and bag valve masks the patient, whilst running the resus from the top end of the bed.
There’s nothing wrong in these situations with raising awareness and simply asking “Who is team leading?” In fact, I encourage nursing staff to do so. I also encourage the nursing staff in smaller centres to have predetermined roles, if an arrest occurred. These are determined at the beginning of a shift, so they can swing into action quickly, which may precipitate more order.
This is a team sport and it needs a Captain.
3 Don’t pause cardiac compressions
The concept of low flow vs no flow is critical to appreciate as it really determines the outcomes of cardiac resuscitation. No flow is when there is no CPR, low flow is when CPR is in progress. The best CPR we can perform will probably provide at most, 50% of that patient’s normal cardiac output. We need to get this right, avoid delays, ensure changeover to maintain speed and depth and keep the blood moving.
The delay in CPR is hard to pick sometimes, unless we are almost militant about it. I was recently called to an arrest and when I walked into the room the anaesthetist had stopped all CPR, whilst trying to intubate. This was a tough resus and sometimes having a point of fixation, helps reduce stress.
The delay in cardiac compressions was becoming significant however, if you noticed it. Sometimes it’s not easy to notice. A delay of 10 -15 seconds, in times of stress passes very quickly and goes unnoticed. In earlier studies done, the delay in CPR to intubate was minutes sometimes. The anaesthetist was alerted to this and stopped the intubation, CPR was recommenced quickly and the patient was bag valve masked until a laryngeal mask was inserted.
All the work that has been done in adult cardiac arrest has shown that endotracheal tubes confer no benefit over bag valve mask or laryngeal mask. The risk of regurgitation in cardiac arrest is very low. The literature demonstrates that for in-hospital cardiac arrests, the outcomes are poor when intubation is attempted early. Why? Because CPR is delayed.
We need to be vigilant, pedantic about continuing CPR.
4 Do not get junior staff to gain intravenous access
Please do not let the most junior staff member attempt IV access, during a resuscitation. This is one of those rate limiting steps. We need to give adrenaline or anti-arrhythmics, and the delay can be significant. A more senior staff member with IV skills, needs to be given the task. That person, must also be able to sink an intraosseous line quickly if the first IV attempt fails. That intraosseous line should be in the head of the humerus.
5 Stop checking for a pulse
Let’s forget about pulse checks. I see them still being attempted and they’re close to useless in a cardiac arrest. When we’re feeling a femoral pulse during CPR we’re just feeling counter pulsations. It tells us nothing about the perfusion. The old belief that a pulse felt at the carotid, gives a minimum systolic blood pressure of 80 mmHg is not right. The blood pressure may be far lower than that and studies have shown it to be less than 60 mmHg systolic.
In a recent workshop I asked delegates to see if they could take my radial pulse, pretending that I was in cardiac arrest and to write down what my rate was. The results were interesting. The numbers varied. What’s amusing, is that I don’t have a palpable radial pulse on that wrist. I’m ulnar artery dominant. Forget about taking the pulse.
6 Get a Femoral Arterial Line in Early
For the last 10 years, we’ve been pushing at the EMCORE Conferences for a femoral arterial line by the third cycle of CPR. I’ve gone through the process in detail several times. First cycle prepare, second cycle ultrasound the femoral triangle and locate the vein and then during the next rhythm check, sink the arterial needle in, under ultrasound guidance, advance the wire and CPR can progress, whilst the procedure is completed.
It’s important to use this for accurately monitoring the cardiac resuscitation. It’s also something we’ll need to have for when there is return of circulation anyway.
Our aim is to provide a minimum diastolic blood pressure, as this is what perfuses the coronary vessels. Aim for 25-35 mmHg of diastolic blood pressure. This means that we can give smaller doses of adrenaline to achieve coronary perfusion.
7 Use Adrenaline the Right Way
There’s been a lot of work on the use of adrenaline in cardiac arrest, including the recent Paramedic Trial. The argument about return of circulation versus neurologically intact survival continues. Let’s think about it a little differently and use adrenaline in the right way.
Firstly, titrate the amount of adrenaline to the required diastolic blood pressure. This is important as we don’t want to give a big dose of adrenaline if we don’t need to. Giving 1mg of adrenaline to an already weakened heart, stresses it, but also increases that vascular resistance it’s pumping against. So now the heart is pumping against a brick wall.
The timing of adrenaline is also important. We’ve spoken about the electrical, circulatory and metabolic phases of the heart before and that continued adrenaline after about 20 minutes or about 3mg may not be of much use.
Better to titrate than to pour it in.
8 Use an Ultrasound during Cardiac Arrest
During cardiac arrest try to use an ultrasound. Remember, you don’t have to be an expert at using the ultrasound. If you can simply pick up a cardiac or abdominal probe and put it on the chest at about the level of the mid-sternum on the left, you can get a good view of the heart.
In our last Cardiac bootcamp, Dr Hansel Addae spoke about rapid ultrasound assessment in an arrest involving the abdominal probe. The assessment is for blood in the belly and then take a quick look at the heart. It takes less than about 3-5 seconds to do. We now teach everyone at the Cardiac and Resuscitation Bootcamps how to perform this simple view.
There are two questions that need to be answered, in respect to the heart;
- Is the heart beating?
If you’re looking at potential pulseless electrical activity this becomes important. Don’t feel for a pulse look with the ultrasound. The “FEEL” study demonstrated that a significant number of patients who were supposedly in PEA actually had coordinated cardiac activity.
- Is there a tamponade?
This is a potential cause of shock prior to arrest but it also becomes very important during arrest especially if lysis is being considered. The other reason its important is that it may indicate that your patient has had a thoracic dissection.
We can go further and look at the right ventricle and the left ventricle, its contractility, its size etc however you don’t have to do all this.
9 How to simply Resuscitate Pulseless Electrical Activity
Forget the H’s and the T’s and look at the complexes themselves. Use this simple QRS width approach to the resuscitation. A narrow QRS complex may indicate an outflow obstruction such as a pulmonary embolism, a tamponade or tension pneumothorax. A wide QRS complex may indicate a metabolic cause such as sodium channel blockade or hyperkalaemia or it may indicate ischemia. It’s easier to treat pulseless electrical activity in this way, than it is to start thinking of the H’s and the T’s.
10 Become an ECG expert: it makes a difference
This isn’t as difficult as people think. If the patient arrests in your Emergency Department the pre-arrest ECG can give us a lot of clues as to what the cause was. Subtle ischemic changes are not an uncommon finding, but are difficult to pick up, unless you know what to look for. You’ve heard me talk about the seven subtle ischaemic changes before:
- Reciprocal Changes
- T Wave Inversion and AVL
- Straight ST Segments
- The QRT sign
- Tall T Waves especially in V3 and V4
- U Wave Inversions
- New Tall Upright T Waves in V1 and certainly when they’re taller than the V Waves in V6
You’ve also heard me talk about diagnosing arrhythmias simply, or the ECG’s of Syncope, or PE at the Bootcamp or on ‘Own the ECG’.
Get better at reading ECG’s. Do an ECG course like ‘Own the ECG’, but you don’t have to do one of my courses, do another course, but get one done. Learn the things that give you the greatest return on your investment of time. ECG knowledge saves lives. The number of patients about to go home in ED’s I’ve worked in, that were stopped due to subtle ECG changes being picked up (with normal troponins and the discharge blessing of the cardiology registrar) still amazes me and shows me that this knowledge does makes a difference. Many of those patients ended up having a cardiac angiogram.
11 Shocking Patients in Asystole
This is probably the most controversial point I make in adult cardiac resuscitation. I’ve mentioned the idea of shocking a patient in asystole before. The use of the ultrasound machine will tell us whether the patient is in true asystole. If you don’t have an ultrasound machine it may be worth giving one shock to these patients. Read the blog on this because it gives you an approach to use. One shock and you’re done.
CONCLUSION
Resuscitation is not easy, it’s tough and it’s unforgiving! People believe it’s protocol based and it is to a point, however, we need to understand and execute those things that maximise survival. Survival is very very low and survival to intact neurological function, even lower. We are the last chance these patients have. Let’s give it the best we can.
Good luck out there!
Peter Kas
