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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, October 12, 2015

Running the code

This week, lets go through some key points on cardiac arrest. Some of these form the fundamentals of CPR in addition to other important points which are not talked about when we do the routine life support courses.

1. High quality CPR
Well, we all know this, Right?
  • Rate:100-120/min
  • Depth: 5cm approximately
  • Allowing full chest recoil
  • Not to hyperventilate
  • Minimising interruptions

This is something that is really stressed on during the life support courses. Well, this is because survival is linked to the quality of CPR and there should not be any excuses here. This is very basic simple stuff that can make a difference. So how are doing it so far?

Current literature says we are slow/ shallow with chest compressions and do not allow adequate recoil. So next time when you run a code, make sure that you stick to these points and especially stay away from interruptions.

Reasons for interruptions: 

a) Airway: Securing the airway should be individualised for every patient. There is no magic number here. For a witnessed arrest with presumed cardiac cause, airway can be delayed for 8-10 minutes whereas early airway control should be done for a hypoxic arrest (drowning, pulmonary edema). In India, pre-hospital intubations are rare and by the time patients are brought to a hospital, airway should be secured ASAP on arrival with minimal interruptions to chest compressions. This is not the time for a novice to try intubation, it should be done by the most experienced provider around. 

b) Pulse Checks: Checking pulse during CPR is unreliable and should not be done, instead use ETCO2 to look for the ROSC. DO NOT STOP COMPRESSIONS TO CHECK FOR PULSE. 

c) Peri shock pauses: Shock can be delivered with transcutaneous pads or paddles and in India, the use of paddles is far more common than pads. 
With every 5 seconds of peri shock pause, there is an 18% decrease in survival. It is recommended to continue to deliver compressions while charging the defibrillator and once it is charged, only then hold the chest compressions for probably < 5 seconds, deliver the shock and resume compressions. It is painful to see those providers, who stop compressions as soon as they touch the paddles, then charge the defibrillator and then deliver the shock. This way it roughly takes about 20-30 seconds.

If there is expertise available, use intra arrest ECHO to pick up a tamponade or dilated RV, but again minimise compressions (Transesophageal ECHO is coming to the ED's soon..)


2. Hemodynamics Guided Resuscitation
Choose one of these three to judge your performance and hemodynamic status:

a) Coronary Perfusion Pressure (needs an arterial line and central line to monitor CPP)
  • Our goal is to achieve an adequate Coronary Perfusion Pressure (CPP) i.e. CPP > 20mm Hg
  • CPP = Aortic DBP - Right Atrial Pressure (RAP) 
OR

b) Diastolic Blood Pressure (needs just an arterial line)
  • Insert a intra arrest femoral arterial line and target DBP > 40mm Hg 
  • If < 40, improve CPR or give epinephrine
  • If > 40, no need to give epinephrine, continue high quality CPR
OR

c) ETCO2 
  • When you can't get an arterial line, use waveform capnography
  • It is the continuous non invasive measurement end tidal CO2 using a sensor, the value is displayed on the monitor as a number.
  • ETCO2 acts as a surrogate marker of cardiac output in addition to confirming the ET tube placement and ROSC.
  • Target ETCO2 > 20mmHg 

3. Medications
Theoretical benefit: Improve CPP, CPP
Detrimental effects: Increase myocardial O2 demand, post ROSC myocardial dysfunction

Epinephrine (Adrenaline)
  • No difference in outcomes, but we are finding it hard to stop using it!!
  • Literature says more epi = no change or worse outcomes.
  • With epi you are more likely to achieve ROSC, but worsen the neurological outcomes.
  • Read more on epinephrine here by Dr. Anand Swaminathan (@EMSwami)
Give q5min epi now if you have been doing q3min so far and watch out for the next ACLS update OR use Hemodynamics Guided Resuscitation. 


3. Team Leadership
  • This is by far the most important take home point from this post. Your leadership skills, ability to mobilise resources and getting things done can affect the outcome of a code. With experience we need to learn how to take control of the situation and communicate effectively under stress. Just knowing the algorithms is not enough.
  • Good Leadership: Appropriate role assignment, better communication, reduces errors and establishes ROSC faster
  • Errors are made due to indecisive and weak leadership which can cost a life.
  • If there is time available, brief your team prior to the code and always debrief after you are done with the code regardless of the outcome. This will improve the team dynamics for future resuscitations. 


So take the charge, assign tasks, be decisive, communicate early, clearly and effectively.

    Take Home:
    • Don't forget the basics, focus on high quality CPR
    • Don't flood them with epinephrine instead use Hemodynamics guided resuscitation (CPP, DBP or ETCO2)
    • Communicate early, clearly and effectively. Good leadership saves lives..

    Thank You


    References:
    1. Michael Winters, MD: Running the Perfect Code in 2015 (AAEM Scientific Assembly) 
    2. Castelao, Ezequiel Fernandez, et al. "Effects of team coordination during cardiopulmonary resuscitation: A systematic review of the literature." Journal of critical care 28.4 (2013): 504-521.CPR quality- Consensus 
    3. Panesar, Sukhmeet S., Agnieszka M. Ignatowicz, and Liam J. Donaldson. "Errors in the management of cardiac arrests: An observational study of patient safety incidents in England." Resuscitation 85.12 (2014): 1759-1763.
    4. Cheskes, Sheldon, et al. "Perishock Pause An Independent Predictor of Survival From Out-of-Hospital Shockable Cardiac Arrest." Circulation 124.1 (2011): 58-66.
    5. Sunde, Kjetil, and Theresa M. Olasveengen. "Towards cardiopulmonary resuscitation without vasoactive drugs." Current opinion in critical care 20.3 (2014): 234-241.
    6. Stiell, Ian G., et al. "Advanced cardiac life support in out-of-hospital cardiac arrest." New England Journal of Medicine 351.7 (2004): 647-656.Johnson NJ et al Resuscitation 2014
    7. Sutton, Robert M., et al. "Hemodynamic-directed cardiopulmonary resuscitation during in-hospital cardiac arrest." Resuscitation 85.8 (2014): 983-986.

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