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Cardiocerebral Resuscitation – Change brings Fantastic results

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Hold on to your brains here people, because I’m about to blow your mind. 

With new research comes new treatment modalities, and with new treatment modalities comes a change in our profession’s very foundation. This change is hard to accept and hard to convince others to implement, but it is necessary for us to do so. 

I’m talking here about CCR, or Cardiocerebral Resuscitation. Hold on, because it’s coming, it’s fantastic, and it will shake the very timbers of our profession.

 First off, if you don’t know what I’m talking about, here are some things you should read first. Go ahead and read them, then come back and read this. I’ll give you a teaser on why you should read forward:

40% – 60% resuscitation rates are possible in witnessed V-Fib cardiac arrests.

 Is that enough incentive for you?

 First, go visit: Http://www.CallandPump.org to read about the ongoing research project.

 Then, read my first post on CCR: “Advances in Resuscitation – CCR, if you’re not doing it now, you will be”

Follow the links on that post to see the article outlining the research project and the subsequent article published in the Annals of Emergency Medicine.

 Did you read them? Good.

 So here are some things you should know about CCR.

 It’s about moving blood – Good compressions make all the difference. Press hard, press fast (100 compressions per minute) and switch out compressors every 1 minute. Yes, do this even though you’re going to complain that I “don’t know how it goes in the field”. Yes, I do because I’m a practicing paramedic with a decade or so of experience and two full-time EMS jobs. I know it’s hard and unwieldy, but the results are almost magical.

 When I first became a CPR instructor for AHA some years ago, I taught my students, incorrectly, that chest compressions were all about compressing the heart between the sternum and the spine. It turns out that I was wrong. The point of effective compressions is to vary total intrathorascic pressure creating both a positive total pressure that forces blood out of every vascular space and organ in the chest including the heart and aorta and also then creating a negative total pressure to pull blood back inside. The more blood you can get flowing, the higher pressure you create in the arteries moving blood through the vascular system and perfusing the heart and the brain. By continuing compressions, you boost the arterial pressure higher to the point where it will perfuse the heart and the brain adequately to maintain some amount of metabolism and prevent some cellular necrosis. When you stop, even for a few seconds, the pressure falls to almost nothing and must be worked back up to the level needed to provide some perfusion of the critical organs. 100 compressions per minute isn’t a request, it’s a mandate if you wish your patient to survive. Switch out compressors every one minute. We’re human beings and we’re fallible. It’s been shown that we cannot maintain adequate compressions for more than a minute. Pop on your ETCo2 monitor and watch the number fall after one person does compressions for longer than that and you’ll believe me.

 Transport is deadly – One of the tenants of CCR is that every intervention that interrupts compressions must be proven to be of more benefit than continued perfusion of the heart and brain. If we are to maintain adequate compressions to continue this perfusion until the heart restarts and begins moving blood on its own, we must not move the patient from a hard, level surface. One of the biggest interruptions of compressions is the act of moving and readying the patient for transport. We jostle them around, put them on a narrow cot, bounce them from wherever they fell, load them into the ambulance, and then bounce them along the road to the ER. All of this decreases arterial pressures by negatively impacting our ability to adequately compress and also by limiting our ability to effectively compress and increase intrathorascic pressures to the extent possible. Therefore, transporting the patient is deadly because it harms our ability to resuscitate our patients.

 Of course I want you to take them to the hospital eventually (hopefully once they’re resuscitated) just don’t be so eager to get them there. Work the patient where you find them. You’ll do your best work on scene and will be pleased with the results.

Be prepared to use more and less common medications – How many medications do you carry on your trucks? One service I work for that doesn’t use the new CCR protocols carries 6 prefilled syringes of Epinephrine 1:10000 on the trucks. Let’s see… One Epi every 3-5minutes x 6 syringes equals 18-30 minutes of epinephrine for the arrests we run. I put the officers on notice that I will be needing a second truck to respond to codes that I attend. In addition, since more patients are being resuscitated, the need to practice post-resuscitative care is increased. Be prepared to hang antiarrythmic drips. Be prepared to hang dopamine. Practice caring for patients post resuscitation. You may want to consider researching induced hypothermia to mitigate reperfusion injury to the heart and brain.

Also, remember that Vasopressin and Amiodarone are in the AHA ACLS protocols. Does your service use them?

Approach cardiac arrest with a clear game plan – If you’re in the emergency services, you should be familiar with the Incident Command System, or ICS. Resuscitations should be no different. One person is the “Code Commander”, one person is the “CPR Sector Officer” and so forth. Train on these like you would train for any other major incident and watch your success rates climb.

I’ll be posting more on this in the coming days. I’m really excited about CCR and the possibilities that it holds for our patients and our profession. You will be too, trust me

Posted by on November 11, 2009 • Filed under: CCC, CCR, cpr, cpr save, ems education, EMS Topics, EMS training, Paramedic, paramedic education, Patient Management, Protocol development, save, Training & Development

Advances in Resuscitation – CCR If you’re not doing it now, you will be

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Visitors to my old blog probably know that at my ambulance service we tend to bring back a lot of codes. I talk about it a lot. Back in 2004 our medical director, Dr. Michael Kellum, got us involved in a “Demonstration Project” to bring Continuous Compression CPR or Cardiocerebral resuscitation to a rural area. Since that time, the results have been more than dramatic. Depending on what statistics you look at, we may be “Saving” almost 50% of witnessed arrests found to be in ventricular fibrillation.

It’s all explained at Http://www.callandpump.org But if you want to go right to the whitepaper that explains what we do, why we do it, and how it’s done then you want to go here: http://callandpump.org/assets/Proposal_Current.pdf – This link is explains the demonstration project initiated by Dr. Kellum et al. in the two county area that I work in. This paper was published in 2004 at the beginning of the project.

This is a link to the results published in the Annals of Emergenc Medicine in 2008 – http://www.ncbi.nlm.nih.gov/pubmed/18374452?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum 

You may be interested in this part:

“RESULTS: In the 3 years preceding the change in protocol, there were 92 witnessed arrests with an initially shockable rhythm. Eighteen patients survived (20%) and 14 (15%) were neurologically intact. During the 3 years after implementation of the new protocol, there were 89 such patients. Forty-two (47%) survived and 35 (39%) were neurologically intact. CONCLUSION: In adult patients with a witnessed cardiac arrest and an initially shockable rhythm, implementation of an out-of-hospital treatment protocol based on the principles of cardiocerebral resuscitation was associated with a dramatic improvement in neurologically intact survival.”

This is good stuff. Remember, the above is only reflective of those included in the study, who are “Witnessed arrest(s) with an initially shockable rhythm”. Anecdotally, I’ve personally attended those that were not in a shockable rhythm and witnessed greater effectiveness as well.

Here’s the short version of our protocols for Witnessed V-Fib Arrest: (and for those of you who want more, email me at: proems1@yahoo.com and I will be happy to send you a copy of the protocols)

We follow an acronym called MCMAID in our resuscitation protocols, it stands for:

Metronome – We carry a metronome in our monitor/defibrillator bags that clicks out at 100 beats per minute. We are to compress at 100bpm. No more, no less. This metronome keeps us on rhythm and reminds us to be on the chest.

Compressions – 100 compressions per minute. Do not stop. Initially, we are to administer 200 compressions (2 minutes) before our first shock. We are to limit any interruptions in compressions absolutely as much as possible, charging our defibrillators while compressions are ongoing, and recognizing V-fib through the compressions if possible. Compress hard and deep, completely releasing tension on the chest upon recoil to maximize the compression and decompression of the chest.

Monitor – Place the monitor on the patient using fast patches. Do not stop the 200 compression cycles to determine the rhythm. Shock at max joules biphasic. If you can anticipate V-Fib, charge the defib during the compressions and only stop long enough to clear for the shock. Don’t check the pulse, get right back to compressions.

Airway – Initially, a BLS airway will be placed in the patient and a non-rebreather oxygen mask will be placed on the patient. If the airway must be controlled by more advanced means to protect and ensure a patent airway, now is the time to do so.

Intravenous Access – Most of the time, this is accomplished through the means of the Ez-IO drill that we carry and love. (See: Alternative Circulatory Access Strategies – Hi Ho IO) This can also be obtained through peripheral or EJ IV access.

Drugs – Epinephrine 1:10,000 1mg IVasopression 40 IU, Amiodarone 300mg, then Epinephrine 1:10,000 1mg q 3-5min. If refractory, we may give an additional 150mg Amiodarone IV.

To see the full MCMAID protocol (I put it up in a post) you can see it by clicking here.

Today Dr. Kellum came down again for our monthly training and let us know the latest breakthroughs and orders in the project. He is stressing the importance of End-Tidal CO2 (ETCO2) monitoring and states that no pulse check is necessary without a spontaneous increase in ETCO2. He expects every intubated (or combitubed) patient to have ETCO2 monitoring in place.

He also expects that we will monitor ETCO2 readings as a way to prove effectiveness of compressions. Rescuers who cannot get ETCO2 readings consistent with other personnel when providing compressions shouldn’t be doing compressions.

Rescuers should switch off compressions EVERY ONE MINUTE whenever possible. This is providing some fantastic results in preliminary trials.

He also stated that the effectiveness of the CCR protocols are showing a marked increase in refractory V-fib. He hinted that the protocols might soon show a need for thrombolytic use in treatment of refractory V-Fib.

Stay tuned folks, I am happy as heck to be included in this. I will bring updates, with permission, as many times as I get them.

Posted by on October 17, 2009 • Filed under: CCC, CCR, cpr, cpr save, DNR, Do Not Resuscitate Order, EKG, Emergency Medical Services, EMS, ems 2.0, ems education, EMS practice, EMS protocols, EMS Topics, EMS training, ET Intubation, ez-io, intraosseous, IO, IV, new perspective, Paramedic, paramedic education, patient care, Patient Management, save, SMG, SMO, southern wisconsin, STEMI, technology-communications-ems-topics, Training & Development • Tagged: , , , ,

MCMAID Resuscitation Protocol

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This post is a stub, and is a supplement to “Advances in Resuscitation – CCR, if you’re not doing it now you will be”

——————

EMERGENCY MEDICAL RESPONDER/EMT

A CODE COMMANDER should assign duties according to MCMAID prior to arrival

  • Establish that the patient is unresponsive, and not breathing normally
  • Rule out DNR status, dependent lividity, rigor mortis

First Priority: M-(metronome) Quality Chest Compressions

  • Turn on Metronome, ensuring a rate of 100/minute
  • Initiate 2 minutes of chest compressions, pediatric-follow AHA 2005 Guidelines

Second Priority: C-(compressions) Quality Chest Compressions

  • Assign two compressors switching every minute, checking each others quality
  • Depth should be at least 2 inches
  • The heal of the compressor’s hand should come off the chest, ensuring full recoil

Third Priority: M-(monitor) Defibrillate

  • AED, push analyze (pediatric patient >1 yr , use peds pads up to 8 yrs if available if not use adult pads)
  • Manual, charge max joules during CPR, analyzing for no more than 5 sec (EMT-I/P) – (pediatric 4 joules/kg)
  • Immediately resume 2 more minutes of compressions

Fourth Priority: A-(airway)

  • Oropharyngeal airway and 10 liters O2 via NRB mask
  • Check patency if chocking is suspected
  • No ventilations until after 3 cycles - (unless pediatric-follow AHA 2005 Guidelines)
  • CombiTube/ET after 3 cycles of compressions, unless 1st  rhythm is nonshockable, then as soon as possible, ventilate at 6/minute only enough volume to just make chest rise

 If ROSC, acquire 12-Lead EKG, ***ACUTE MI SUSPECTED*** see STEMI Guidelines.

Give a status report to the ambulance crew by radio ASAP and ensure ALS has been dispatched.

 AEMT

Fourth Priority: I-(IV) Establish venous access

  • Initiate IO 0.9% Normal Saline unless IV is assured and quick, run wide open (20ml/kg boluses for pediatric patients)
  • Consider second IV and chilling both for unresponsive ROSC. Refer to Therapeutic Hypothermia Procedure

 INTERMEDIATE

 Monitor basic rescuer interventions closely, ensure quality, uninterrupted chest compressions

Fifth Priority: D-(drugs) Proceed to ACLS resuscitation medications

  • Obtain venous access, if not already done
  • Epinephrine 1:10,000 1 mg IV/IO every other cycle of compressions (4 minutes)
  • Vasopressin 40 units IV/IO, repeat dose in 10 minutes if no ROSC
  • If multiple shocks have been given, Amiodarone (Cordarone) 300 mg IV/IO, followed by another 150 mg if still refractory (shocks being delivered)
  • After 3 cycles of compressions, (unless first rhythm in non shockable) place advanced airway without interrupting compressions and begin ventilations at 6/minute, using only the volume to just make the chest rise.
  • If initially non-shockable, Identify and correct reversible causes: The Five H’s and the Five T’s This applies mostly to PEA, but to a lesser extent, Asystole, as well.
  • If rate is <60, Atropine Sulfate 1 mg IV. Repeat every 3 – 5 min to a maximum of 3 mg

 “The Five H’s” (treatment orders are in parentheses)

  1. Hypovolemia (Infuse Normal Saline wide open)
  2. Hypoxia (Place an advanced airway and administer high-flow oxygen at a ventilation rate of 6/minute with only enough volume to make chest rise. [1])
  3. Hydrogen Ion, i.e. acidosis (Perform ventilation [1])
  4. Hyperkalemia [2]
    1. Give Calcium Chloride (10%) 1000mg IV over 2 – 5 minutes. May repeat X 1
    2. Give Sodium Bicarbonate (8.4%) 50 mEq IV
    3. Give Albuterol Sulfate 2.5 mg HHN may repeat X 1
  5. Hypokalemia (not treated in the field.)
  6. Hypothermia (See Hypothermia & Frostbite Guidelines)

“The Five T’s” (treatment orders are in parentheses)

  1. Tablets (See Toxic Exposure/Overdose Guidelines)
  2. Tamponade (EMT-P: Perform Pericardiocentesis)
  3. Tension pneumothorax (Perform needle decompression)
  4. Thrombosis, cardiac i.e. myocardial infarction (See Chest Pain Guidelines)
  5. Thrombosis, pulmonary i.e. pulmonary embolism (No specific pre-hospital treatment available)

Paramedic

 If there is ROSC, as seen as a sudden large increase in EtCO2 and/or patient movement

  • Give Amiodarone (Cordarone) 150 mg IV/IO over 10 minutes, if multiple shocks given
  • Reassess the need for airway devices
  • Maintain advanced airway, if the patient remains unconscious
  • If the patient wakes up, the airway may be removed. Use the procedures for removing advanced airway devices in the Respiratory Distress Guidelines.
  • Monitor patient’s EtCO2 and ventilate accordingly (12-20 per minute to maintain EtCO2 around 35 mmHg)
  • Maintain SBP >80 mmHg, Consider Dopamine Hydrochloride 10-20mcg/kg/minute IV infusion
  • Consider inducing hypothermia, See Therapeutic Hypothermic Guidelines
  • Consider RSI See Respiratory Distress Guidelines
  • If post-resuscitation 12-lead EKG shows STEMI refer to STEMI Guidelines
  • Contact Medical Control for the following:
    • To discuss termination of resuscitation in the absence of a valid Wisconsin DNR Bracelet
    • Additional medication orders

 FOOTNOTES:

 1. Do not hyperventilate during cardiac arrest, even if hypoxia and acidosis are suspected causes. Strictly follow the ventilation guidelines described above.

2. Suspect Hyperkalemia when patients with a history of chronic renal failure (dialysis patients) develop cardiac arrest. Pre-arrest history may include weakness, missed dialysis appointment(s), vomiting, concurrent illness, and T waves that are peaked and as large as the R wave.

—————————-

This post is a stub, and is a supplement to “Advances in Resuscitation – CCR, if you’re not doing it now you will be”

Posted by on October 17, 2009 • Filed under: CCC, CCR, cpr, cpr save, DNR, Do Not Resuscitate Order, EMS paramedics, EMS practice, EMS protocols, EMS Topics, intraosseous, intubation, IO, Paramedic, paramedic education, patient care, Patient Management, SMG, SMO, Uncategorized

Alternative Circulatory Access Strategies – Hi Ho IO

6 comments

A while back ago, Steve over at http://theemtspot.com wrote a great post on Gaining IV Access. In the post, he’s got some great strategies for getting your IV starts every time.

But, as we all know, sometimes you just can’t get the darn catheter to go into that tiny vein for whatever reason. Try as you might, it seems like you’re going to be turning the patient into a pincushion before you establish your IV access. Sometimes that’s fine, when the patient is pretty much stable and you just need access. But when the fit’s hitting the shan, you’ve got to step it up. Luckily, our friends in the medical product industry have been working hard to beef up our firepower.

My favorite alternative way to make holes in people’s circulatory system is this:

The EZ-IO or, the intraosseous Drill, is a great way to get a big circulatory access point in a hurry. It’s stable, it’s reliable, and works in a hurry. I’ve used it and we carry it on every ambulance that I work on. I don’t do paid endorsements, but if the company that made this wanted to offer me a ridiculous sum of money to endorse this product, I would.

Intraosseous infusion was just for pediatrics when I first got into the game. We carried the Illinois bone marrow aspiration needle and used it for bad peds. We still do, and the thought of jamming that big ol’ needle into a baby’s tibia still gives me a touch of the heebie jeebies. However, I have to say that it’s one of those things that is absolutely needed when it is indeed needed. Adult patients weren’t so lucky. Before the EZ-IO came about if we couldn’t get a vein in the field with an IV cath on a critical patient, chances are the patient would have to wait for a central line in the hospital. Sure, we can attempt access in the external jugular vein one time and we can always give endotracheal doses down an ET tube in cardiac arrest situations, but I don’t really like any of those methods. The EJ because of the risks involved, and the ETT method because I’ve never really seen it be effective nor read any really positive research on the method.

Now, with the EZ-IO that’s changed. For our service, with cardiac arrest save rates between 40 and 60% depending on the literature you’re reading (Really. www.callandpump.org) most of our medics don’t attempt an IV on a code. If they, or I, am the only advanced level provider, the patient is “drilled” right off and that is our only circulatory access point during the initial resuscitation effort. If there is an EMT-IV tech, EMT-Intermediate, or an additional paramedic present, I will attempt one AC IV placement or direct it to be attempted, however I will most likely drill the patient for secondary access. For most truly critical patients, I place two IV sites. One is capped and acts as a backup site unless aggressive fluid resuscitation is needed or another provider takes over the medication part of the resuscitative team.

There’s been only one study that I’ve found on the effectiveness of the EZ-IO… and yes, this comes from the manufacturer’s web site… but I give them a modicum of credibility because they’re not selling something that hasn’t been around for quite some time as a viable method.

Q. Is IO better or just equal to IV for fluid, drug delivery?

A. The only human IO pharmacokinetic trial reported that IO flow levels are equal to that of IV as supported in the ACLS guidelines issues in December 2005.  Drugs injected into the IO space of the tibia, sternum and humeral head all reach the central venous circulation within one second which is faster than drugs given through IV in a low flow perfusion state

and this:

Q. What are the risks with this product – infection, leakage, bone not healing?

A. The documented overall complication rate associated with intraosseous insertion and infusion is less than 1 percent.  Potential complications include extravasation (leakage), dislodgement of the needle, compartment syndrome, bone fracture, pain related to infusion of medications/fluids and infection.  To date, there have been no reported complications from use the EZ-IO® product system. Overall IO experience in thousands of children and 4,000 adults show the infection rate to be less than 0.6 percent and those are usually not serious and can be treated as outpatients.

Medical mumbo jumbo, I know. I just love this tool. You should have it and use it too. I’ve seen it save lives, save outcomes, and make life much easier on poor, overworked paramedics.

Of course, that’s not to say that there aren’t alternative IO tools out there. I’ve been through a class on the BIG: Bone Injection Gun, and while I’ve heard generally positive things about it, I’ve never used it personally. I also have not had the chance to use the sternal IO access device (I believe it’s called the FAST Sternal IO) however, I found this video on it that came from the military medics that do use it.

Yes, that guy is CONSCIOUS.

Yes, it gives me the heebie jeebies to watch that. I’ll let students practice their IV skills on me… but A FREAKING STERNAL IO!? Those military guys have my respect, because they’re crazy. He didn’t even whimper when another guy was JABBING 6 NEEDLES INTO HIS BONE!

Although, I did get tazed for love one time. I guess I’m crazy too.

Thanks for reading, y’all.

Posted by on September 20, 2009 • Filed under: ALS Intercept, CCC, CCR, Emergency Medical Services, EMS, ems education, ez-io, intraosseous, IO, Paramedic, paramedic education

A very cool site

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Want to learn something? This site: Http://www.callandpump.org is the flavor of CPR I do. I’ve been getting some real “Kick the Grim Reaper in the Balls” saves with it.

You should read about it too.

Posted by on June 20, 2009 • Filed under: Ambulance, CCC, CCR, cpr, cpr save, EMS, EMT, Paramedic, save
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