WEEK 3 Hpcpr (high performance CPR)- paramedicine PDF

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Study notes for paramedicine 2021 semester 2...

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WEEK 3: HPCPR (high performance CPR) Cardiac arrest: an abrupt loss of blood flow that results from failure of the heart to pump effectively. A cardiac arrest can be primary or secondary depending on the underlying cause. -

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A primary cardiac arrest is where the arrest is clearly caused by a cardiac problem ( or there is no obvious cause). Secondary arrest is when there is an obvious non-cardiac cause such as drowning or asthma. A patient is said to be in cardiac arrest if they are unconscious and have no sign of life. The patient may have agonal respirations but this is not considered a sign of life. Cardiac arrest remains a considerable public health issue, with ischaemic heart disease being the second most prevalent cause of death in New Zealand. Every year in New Zealand over 2,000 people are treated for cardiac arrests in the community, with only 1 in 10 surviving to 30-days.

Resuscitation: cardiopulmonary resuscitation (CPR) is a coordinated sequence of chest compressions and ventilations, with the aim to preserve myocardial and cerebral perfusion.

High performance CPR (HPCPR): this is only used on primary cardiac arrests

● Good CPR is the foundation of effective resuscitation - without it, the benefit of other interventions is lost. ● Chest compressions result in an alternating positive and negative pressure within the thoracic cavity which acts as a pump to facilitate blood flow. ● Compression creates a positive pressure in the cavity which results in blood leaving the heart and flowing forwards. ● Decompression creates a negative pressure as the ribs spring outwards and blood is sucked back into the thorax and heart. ● CPR helps to maintain ATP levels which are essential for cellular function. ● Without sufficient ATP, defibrillation may terminate the shockable rhythm but the heart may not have enough energy to revert to a perfusing rhythm, instead it may deteriorate to PEA (no mechanical output) or asystole (no electrical output). ● Perfusion of organs occurs during the compression phase ● Coronary perfusion occurs during the decompression/relaxation phase ● Therefore we need to ensure adequate depth and recoil of compressions to ensure both the heart and organs are well perfused. Quick recognition of cardiac arrest: Previously, we have spent prolonged periods of time assessing a patient to see whether they were breathing and/or had a pulse over 10-20 seconds. It was found that we are fairly poor at finding pulses in these circumstances and this was resulting in a delay in starting resuscitation. Agonal breathing is common is NOT a sign of life Specific gear placement and personnel placement: HPCPR has a standardised approach to gear and personnel placement that must be followed. It is designed to create a clean scene in which everybody knows what they are doing and where things are. This allows for better coordination and team work. We want to create a 'HPCPR Triangle' ● The ventilation/airway officer is positioned directly at the head of the patient. In a 2-person resus, this person is also in charge of the defibrillator.

● The chest compressor is positioned off to the right side of the patient ● Note where all of the gear is situated in the diagram and it should all be easily reachable. The airway dump is the area that you will place all of your prepared airway gear for your off-sider to insert- this ensures that it is all together and does not get lost. Movement should always be in a clockwise direction and never stepping over the patient or gear that may cause you to trip. Effective CHEST COMPRESSIONS with minimal interruption: Good chest compressions are a fundamental of HPCPR and therefore one of our main priorities in any resuscitation. Technique - Key points: Hands positioned in the centre of the chest Body positioned close and high Shoulders directly over patients chest with arm perpendicular to ground Strong core Elbows locked Push down with heel of your hand Compress 1/3 of the chest 110bpm Fully recoil using the palm lift technique Minimise interruptions Perfusion pressure is a primary predictor of cardiac arrest survival Perfusion pressures gradually increase with continuous CPR Even short pauses in CPR will result in a rapid decline in perfusion pressure ● 20-25 seconds to achieve adequate flow but drops immediately ● Keep any pauses in compressions less than 3 seconds ● ● ● ● ● ● ● ● ● ● ● ● ●

Common interruptions in CPR include distraction, ventilation, changing roles, rhythm checks, advanced airway insertion or prep, moving the patient and poor organisation.

Rate - 110bpm: ● Rates between 100-120/min allow for sufficient cardiac filling and blood flow. 110bpm is optimal. ● You must use a metronome set to 110bpm during HPCPR to assist with maintaining the correct rate. There is good research which demonstrates that survival rates start to fall off at rates less than 100 (not enough blood flow) or greater than 120 (not enough time to refill, reduced venous return).

Depth: ● Aim to compress 1/3 of the patients chest or approx 5cm in an adult ● Too shallow = inadequate blood flow ● Too deep = can cause physical trauma Recoil: ● Incomplete recoil or leaning on the chest after performing the compression motion, markedly reduces perfusion pressures in the brain and myocardium and therefore impacting patient outcomes ● Relaxation of the heart (recoil) also allows for coronary (heart) perfusion. Incomplete recoil will result in the heart getting inadequate perfusion. ● In HPCPR we use the palm-lift technique to ensure adequate recoil. This involves the palms momentarily bouncing off of the chest at the top of the decompression phase before compressing down again. Yannopoulos et. al showed that 75% decompresssion (as opposed to the optimal 100% decompression) does not provide adequate coronary or cerebral perfusion pressures to achieve ROSC.

Rotate compressor every 2 minutes (or sooner if fatigued): ● Research suggests that the quality of chest compressions decays significantly after 2 minutes. The more tired we get, the worse they become. ● A study found that after 2 minutes only 67.1% of compressions are correct, after 3 minutes 39.2% and after 5 minutes 18%. ● Evidence also suggests that we are unlikely to recognise fatigue in

ourselves- it is likely going to be another team member that identifies the issue. ● We aim to rotate compressors every 2 minutes. If the compressor fatigues earlier then they may be swapped out sooner but this must be a coordinated swap that minimises any time off of the chest.

Hover!: ● In order to minimise any interruptions in chest compressions when we deliver a shock or ventilations, the compressor should 'hover' over the chest. This ensures they are prepared and in a position to immediately resume compressions as soon as the action is completed. ● Avoid sitting back or removing your hands too far as this delays ongoing compressions ● The officer in charge of defibrillation will instruct the compressor to hover by giving them a shoulder tap and saying "pause". Automated external defibrillator (AED):

Along with effective CPR, early defibrillation is a main priority and should always take priority over the airway during HPCPR. Apply the pads as per the pictures on the pads. We need to make sure this is done correctly to ensure the shock travels across the myocardium. Place one on the right chest, just below the collarbone and the other on the lower left lateral chest. Remove any clothing or jewelry and place pads on the patients bare chest. If the patient is wet, dry the chest first. If they have thick chest hair this requires removing quickly as it may impact the pad contact with the chest (most AED contain a disposable razor) The AED will provide verbal prompts. We want to continue compressions until the AED advises that it is analysing - we need to STOP compressions during the analysis phase as the AED is interpreting the cardiac rhythm and compressions will interrupt and delay this. This should be done with a shoulder tap and saying "pause". Once the AED determines whether a shock is advised or not, compressions should recommence immediately.

If a shock is advised, you need to momentarily pause the compressor ( < 3sec) and press the shock button. If no shock is advised, continue CPR.

AED - it's role ● It is important to note that an AED cannot not tell you whether or not a patient is in cardiac arrest. It's role is only to analyse the heart to establish whether the patient is in a shockable rhythm or not. ● The only two shockable rhythms are: Ventricular Fibrillation (VF) (erratic fibrillation of the heart muscle) or Ventricular Tachycardia (VT) (contraction of the ventricles that occurs so quickly the heart does not have time to refill meaning there will be no blood physically being pumped out with each contraction.) In practice if the AED advises that no shock is needed, this does not mean that a patient is not in cardiac arrest, it means that they are not in either of these two rhythms, they could either be in asystole (flat line), or pulseless electrical activity (PEA). Use your clinical judgement, you are sometimes a lot smarter than an AED, if the patient looks like they are in cardiac arrest, they are in cardiac arrest and need to be treated that way. If the AED advises "no shock" continue with CPR as per normal. HPCPR works under a similar concept to CRM where we use a 'sterile cockpit' approach to communication, meaning that verbal communication in the scene is minimised to maintain control and order. ● "Pause" ● "Swap" ● "Shocking" The officer in charge of the defibrillator is in charge of providing these commands and they should always be coupled with a shoulder tap (closing the loop). Set Individual Roles and Team Work: There a selection of set roles in HPCPR that outline individual responsibilities. This semester there will only be two responders in your scenario. It is important that you understand the individual responsibilities associated with each role and how they change when you rotate.

Airway management and ventilation: Ventilation has a lower priority than chest compressions and defibrillation. Can be managed with a basic airway adjunct (OPA/NPA), BVM and a good head position (Head-tilt-chin-lift). The ratio of compressions to ventilations with a basic adjunct is 30:2 - Ventilations should be with a BVM. We need to be conscious to not hyperventilate the patient as it increase intrathoracic pressure which in turn reduces the development of negative pressure during the decompression phase of

compressions. This means there is less alternating pressure inn the chest, reducing blood flow and impacting patient outcomes. We do not insert the OPA/NPA/LMA until the third cycle of an arrest after the second rhythm check. Defibrillation and CPR take priority after every rotation before attention is moved to airway. Ventilate using the rule of 3's ● Three fingers holding the bag (bottom third of bag) ● Compress a maximum of 1/3 of the bag ● Deliver both ventilations in less than 3 seconds...