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Tuesday
Jan262016

Systems of Care and Continuous Quality Improvement

Bob Elling, MPA, EMT-P

(Part 2 of a 6-part series: CPR, ECC, and First Aid Guidelines: Version 2015)

A number of topics were addressed in the 2015 Guidelines on systems of care and continuous quality improvement (CQI) that will be incorporated into updated protocols and procedures. This section is extremely important, as those communities that take the time to focus on improving all the links in the chain of survival will see the greatest improvements in survival. Whose responsibility is this? All of us have a responsibility as first aiders, EMS providers, health care professionals, and interested members of the public to step up and help implement all sections of the Guidelines!

Let’s take a closer look at the specifics here.

Public-Access Defibrillation

  • It is recommended that PAD programs for patients with OHCA be implemented in communities at risk for cardiac arrest (Class I).

Dispatcher Recognition of Cardiac Arrest

  • It is recommended that emergency dispatchers determine if a patient is unconscious with abnormal breathing after acquiring the requisite information to determine the location of the event (Class I).
  • If the patient is unconscious with abnormal or absent breathing, it is reasonable for the emergency dispatcher to assume that the patient is in cardiac arrest (Class IIa).
  • Dispatchers should be educated to identify unconsciousness with abnormal and agonal gasps across a range of clinical presentations and descriptions (Class I).
  • We recommend that dispatchers provide chest compression-only CPR instructions to callers for adults with suspected OHCA (Class I).

Use of Social Media to Summon Rescuers

  • Given the low risk of harm and the potential benefit of such notifications, it may be reasonable for communities to incorporate, where available, social media technologies that summon rescuers who are willing and able to perform CPR and are in close proximity to a suspected victim of OHCA (Class IIb).

Transport to Specialized Cardiac Arrest Centers

  • A regionalized approach to OHCA resuscitation that includes the use of cardiac resuscitation centers may be considered (Class IIb).

Immediate Recognition and Activation of the Emergency Response System

  • It is recommended that emergency dispatchers determine if a patient is unresponsive with abnormal breathing after acquiring the requisite information to determine the location of the event (Class I).
  • If the patient is unresponsive with abnormal or absent breathing, it is reasonable for the emergency dispatcher to assume that the patient is in cardiac arrest (Class IIa).
  • Dispatchers should be educated to identify unresponsiveness with abnormal breathing and agonal gasps across a range of clinical presentations and descriptions (Class I).

Untrained Lay Rescuer

  • Untrained lay rescuers should provide compression-only CPR, with or without dispatcher assistance (Class I).
  • The rescuer should continue compression-only CPR until the arrival of an AED or rescuers with additional training (Class I).

Trained Lay Rescuer

  • All lay rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest (Class I). In addition, if the trained lay rescuer is able to perform rescue breaths, he or she should add rescue breaths at a ratio of 30 compressions to 2 breaths.
  • The rescuer should continue CPR until an AED arrives and is ready for use or until EMS providers take over care of the victim (Class I).

Health Care Provider

  • It is reasonable for health care providers to provide chest compressions and ventilation for all adult patients in cardiac arrest, from either a cardiac or noncardiac cause (Class IIa).

Delayed Ventilation

  • For witnessed OHCA with a shockable rhythm, it may be reasonable for EMS systems with priority-based, multitiered response to delay positive-pressure ventilation by using a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts (Class IIb).

Recognition of Arrest

  • Dispatchers should instruct rescuers to provide CPR if the victim is unresponsive with no normal breathing, even when the victim demonstrates occasional gasps (Class I).

Suspected Opioid-Related Life-Threatening Emergency

  • For a patient with known or suspected opioid overdose who has a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard BLS care, it is reasonable for appropriately trained BLS health care providers to administer intramuscular or intranasal naloxone (Class IIa).
  • For patients in cardiac arrest, medication administration is ineffective without concomitant chest compressions to ensure drug delivery to the tissues. Thus naloxone administration may be considered after initiation of CPR if there is high suspicion for opioid overdose (Class IIb).        
  • It is reasonable to provide opioid overdose response education with or without naloxone distribution to persons at risk for opioid overdose in any setting (Class IIa).

Chest Compression Rate

  • In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120 compressions per minute (Class IIa).

Chest Compression Depth

  • During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches [6 cm]) (Class I).

Chest Wall Recoil

  • It is reasonable for rescuers to avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest (Class IIa).

Minimizing Interruptions in Chest Compressions

  • In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible (Class I).
  • For adults in cardiac arrest receiving CPR without an advanced airway, it is reasonable to pause compressions for less than 10 seconds to deliver 2 breaths (Class IIa).
  • In adult cardiac arrest with an unprotected airway, it may be reasonable to perform CPR with the goal of keeping the chest compression fraction as high as possible, with a target of at least 60% (Class IIb).

Layperson: Compression-Only CPR Versus Conventional CPR

  • Dispatchers should instruct untrained lay rescuers to provide compression-only CPR for adults with sudden cardiac arrest (Class I).
  • Compression-only CPR is a reasonable alternative to conventional CPR in the adult cardiac arrest patient (Class IIa).
  • For trained rescuers, ventilation may be considered in addition to chest compressions for the adult in cardiac arrest (Class IIb).

Open the Airway: Lay Rescuer

  • For victims with suspected spinal injury, rescuers should initially use manual spinal motion restriction (eg, placing a hand on either side of the patient’s head to hold it still) rather than immobilization devices, because use of immobilization devices by lay rescuers may be harmful (Class III).

Bag-Mask Ventilation

  • As long as the patient does not have an advanced airway in place, rescuers should deliver cycles of 30 compressions and 2 breaths during CPR. The rescuer delivers breaths during pauses in compressions and delivers each breath over approximately 1 second (Class IIa).

Ventilation With an Advanced Airway

  • When the victim has an advanced airway in place during CPR, rescuers no longer need to deliver cycles of 30 compressions and 2 breaths (ie, they no longer need to interrupt compressions to deliver 2 breaths). Instead, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed (Class IIb).

Passive Oxygen Versus Positive-Pressure Oxygen During CPR

  • We do not recommend the routine use of passive ventilation techniques during conventional CPR for adults, because the usefulness/effectiveness of these techniques is unknown (Class IIb).
  • In EMS systems that use bundles of care involving continuous chest compressions, the use of passive ventilation techniques may be considered as part of that bundle (Class IIb).

CPR Before Defibrillation

  • For witnessed adult cardiac arrest when an AED is immediately available, it is reasonable that the defibrillator be used as soon as possible (Class IIa).
  • For adults with unmonitored cardiac arrest or for whom an AED is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied, and that defibrillation, if indicated, be attempted as soon as the device is ready for use (Class IIa).

Analysis of Rhythm During Compressions

  • There is insufficient evidence to recommend the use of artifact-filtering algorithms for analysis of ECG rhythm during CPR. Their use may be considered as part of a research program of if an EMS system has already incorporated ECG artifact-filtering algorithms in its resuscitation protocols (Class IIb).     

Timing of Rhythm Check

  • It may be reasonable to immediately resume chest compressions after shock delivery for adults in cardiac arrest in any setting (Class IIb).

Chest Compression Feedback

  • It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance (Class IIb).


The next section of this blog will address specifics in the area of adult advanced cardiovascular life support and ACS. If you want to read all the details and background, take a look at the Supplement to Circulation, volume 132, number 18, supplement 2, November 3, 2015.

See you in the streets! 

 

Friday
Jan152016

Register for the ECSI Guidelines Webinar on 1/20

You're Invited!

Join ECSI for an online meeting to explore the medical content changes found in the 2015 guidelines and information surrounding the release of our new training programs!

ECSI 2015 Guidelines Webinar

January 20, 2016 at 2:00 PM (EST)

 

Registration for the webinar will be free for all ECSI Education Center coordinators and instructors.

 

Friday
Jan082016

CPR, ECC, and First Aid Guidelines: Version 2015

Bob Elling, MPA, EMT-P

(Part 1 of a 6-part series)

Introduction to the 2015 Guidelines Changes

If there is one thing we can rely on in the medical field, it is change. Because many of the treatments we provide are often being evaluated in scientific studies, it has come to be an expectation that evaluation of the evidence will help guide our practice. When I was in my initial paramedic course, the physician who taught us made this statement: “About a third of what you are learning will be considered wrong in 10 years. The problem is we do not know which third.” Most of us who have practiced for a few decades can see the truth in that statement.

At 5-year intervals, experts in resuscitation from across the world publish a consensus on what the science of resuscitation tells us. It is that publication, and the process that leads up to its development, that rolls out in the United States as the “Guidelines.” The resulting documents were recently published in two peer-reviewed journals.

Resuscitation and Circulation

As you know, major changes were made to CPR and ECC practices in the 2005 Guidelines. The emphasis turned to improving the quality of chest compressions and strengthening the links in the chain of survival in every community. These changes were reinforced in 2010. The 2015 version of the Guidelines has just been published. So what does the first half of 2016 have in store for us as these updates roll out?

The good news is that clearly those communities that have implemented the spirit of the 2010 Guidelines are on the right track and are seeing success in terms of lives saved. I would sum up the 2015 Guidelines as a combination of defining limits, emphasizing teamwork, and focusing on high quality.

Looking at the new Guidelines from a “10,000-foot level” my initial impressions are as follows:

  • There are not a lot of major changes, so incorporating the Guidelines into practice should be relatively “painless.”
  • Because ILCOR and AHA are both working on first aid guidelines, there are a number of recommendations in this topic area (ie, naloxone for overdose, glucose for hypoglycemia, assisting with a bronchodilator, giving ASA to heart attack patients, no more pressure points or elevation for bleeding control, no more occlusive dressings for open chest trauma, assessing for stroke, spinal motion restriction and no collar for laypersons).
  • There are now maximums on both the rate of compression (100 to 120) and the depth of compression (2 to 2.4 inches).
  • There is a difference between the links in the chain of survival for out-of-hospital care versus in-hospital care. In-hospital care now stresses prevention.
  • There is no longer any reason to carry vasopressin, because it has no advantage over epinephrine and should not be used in pregnant women.
  • Although TTM (targeted temperature management) post ROSC is a Class I intervention, it should be done in the hospital and not with cold IV fluid in the field.
  • Trendelenburg position is back for nontraumatic causes of shock.
  • The Guidelines state several times that the frequency of training should be more often than once every 2 years.

The ECSI team of authors and editors is working very hard to update its instructor network, and to update any and all of our materials so that everyone who uses our valuable products can continue to train students to save lives.

Over the next five segments of this blog series, many of the specific recommendations will be listed. These specific topics will be covered:

Part 2: Systems of Care and Continuous Quality Improvement

Part 3: Adult Advanced Cardiac Life Support and ACS

Part 4: Special Circumstances of Resuscitation

Part 5: Pediatric Basic and Advanced Life Support and Cardiopulmonary Resuscitation Quality

Part 6: First Aid

Each recommendation in the Guidelines has a “class of recommendation” that corresponds to the strength of the recommendation and the quality of the scientific evidence that backs up the recommendation. The classes include:

Class I: strong

Class IIa: moderate

Class IIb: weak

Class III: moderate and provides no benefit

Class III: strong and causes harm

It is important to note only topics that changed are listed. Note also that I have not listed the levels of evidence, ethical issues, alternative techniques and ancillary devices to CPR, education, and neonatal topics. If you want to read all the details and background, take a look at the Supplement to Circulation, volume 132, number 18, supplement 2, November 3, 2015.

See you in the streets!

Monday
Nov232015

Coming Soon: New ECSI Training Programs

Our ECSI team of authors and subject matter experts are currently working on a new line of training materials that will be released starting early in 2016 to cover the latest medical recommendations outlined in the 2015 International Consensus Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) guidelines. 

Tuesday
Oct272015

ECSI's Top 5 Things to Remember About the CPR Guidelines Transition


  1. The 2015 CPR and ECC Guidelines have been released, but you don't have to worry about implementing all the changes just yet. 
    Resuscitation scientists and experts worldwide work together to provide these guidelines to continuously improve cardiac resuscitation efforts and ultimately, save more lives. The release of new medical recommendations in the guidelines does not imply that the use of previous recommendations is not effective or unsafe, so...

     
  2. Our current ECSI training programs are still safe and effective resources to rely on!
    Check out our ECSI Training Catalog for a complete list of available resources.

     
  3. We will be rolling out a new line of ECSI training programs starting in early 2016. 
    Changes to our ECSI training programs do not happen immediately. Our team of authors and subject matter experts are currently working on a new line of training materials that will be released in early 2016 to cover the latest medical recommendations outlined in the 2015 Guidelines. 

     
  4. We will communicate with you regularly to keep you up-to-date. 
    Whether you're looking for a schedule of release dates on our new training programs or would like a step-by-step process of how the ECSI Online Instructor Update will work—we have you covered. Make sure you sign up to receive ECSI email communication, check back for updates on our ECSI blog, and become a fan of our ECSI Facebook page for regular and timely updates.

     
  5. We're here to help make the transition process EASY.
    If you have any questions or concerns, please contact us today:
    800-716-7264  |  info@ECSInstitute.org