Greenacres Fire Rescue Procedures for EleGARD - Elevated CPR PDF

GREENACRES FIRE RESCUE PROCEDURES FOR ELEGARD – ELEVATED CPR Therapeutic Goal To recognize the patient requiring cardiopulmonary resuscitation and to restore a stable cardiac rhythm with adequate cardiac output and perfusion leading to neurologically intact survival. Assessment / Pathophysiology Th...

GREENACRES FIRE RESCUE PROCEDURES FOR ELEGARD – ELEVATED CPR Therapeutic Goal To recognize the patient requiring cardiopulmonary resuscitation and to restore a stable cardiac rhythm with adequate cardiac output and perfusion leading to neurologically intact survival. Assessment / Pathophysiology This guideline is for medical cardiac arrest and does not apply to traumatic arrest. Cardiopulmonary arrest can be primary – from a cardiac event (e.g., MI, arrhythmia, etc.) – or secondary – relating to hypoxia from a FBAO, CHF, drowning, OD, etc. The majority of OHCA (Out of Hospital Cardiac Arrest) is due to cardiac etiology. High-quality, uninterrupted cardiopulmonary resuscitation (CPR) and early defibrillation are the hallmarks of successful neurologic outcomes in OHCA. The best chance for survival from sudden cardiac death is associated with consistent highquality CPR provided as soon as possible upon discovery of the condition. Efforts should be made to perform compressions that allow for adequate rate and depth with full chest recoil, while limiting interruptions. In general, when the scene is safe, all cardiac arrests with an initial rhythm that is not shockable/ no shock advised, should be worked on scene for a minimum of thirty (30) minutes. It is acceptable to stay longer if conditions warrant. It is always better to move a patient with ROSC than try to work a cardiac arrest in an organized fashion while moving. Greenacres Fire Rescue utilizes a “bundle of care” approach that should be employed for almost all medical cardiac arrests. The different elements of this approach act synergistically to improve perfusion and enhance success. Initial Patient Management • • • • • • Respond to patient side with EleGARD, LUCAS device, Cardiac monitor, and Airway/Medication Backpack. Additional equipment may be brought to patient by next arriving unit(s). Assure the patient is pulseless and that resuscitation is indicated. If there is doubt about whether to start a resuscitation, start the process and notify Supervisor. Perform a rapid scene survey for any evidence of a valid DNR / DNI. Start CPR immediately. Apply EleGARD as soon as available, device will aid in positioning the airway for I-Gel or ETT insertion. Insert I-Gel with ResQPOD, filter and ETCO2. Page | 1 REV. 08/2022 GREENACRES FIRE RESCUE PROCEDURES FOR ELEGARD – ELEVATED CPR • • • If AED has been placed by first responders, follow prompts. Switch to Zoll monitor when available and practical. If AED or Zoll has recognized initial rhythm as shockable, follow Standing Orders. Utilize time in-between procedures to optimize care and trouble shoot any H’s and T’s. Utilize Command Style Patient Management • • Assign tasks using a command approach (tasks include compressions/LUCAS, ventilations, EleGARD, monitor/meds, assistant, and data collection). There must be a defined leader for each cardiac arrest team for it to run smoothly. Ensure High Quality Compressions • Ensure high quality compressions are performed continuously throughout the code. CPR ▪ ▪ ▪ Rotate CPR duties every two (2) minutes to avoid fatigue. Aim for no break in compressions, if needed, any interruption should be less than five (5) seconds. (Airway placement / intubation / movement / defibrillator charging / rhythm check). Continue to provide continuous chest compressions at 100/min. Do not pause compressions for ventilations once an airway is in place. Avoid using two hands to squeeze the bag to prevent excess tidal volume. Turn on ResQPOD timing assist lights and provide asynchronous ventilations; ventilate once (over one (1) second until chest rises) each time light flashes (10/min). EleGARD and LUCAS ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Power on the EleGARD device (Button 1) and place under patient as soon as possible. (Interruption in CPR should be < 5 seconds, when placing EleGARD). Note the time that the EleGARD is placed. Goal for placement is < 4 minutes after arrival. Switch from manual CPR to LUCAS. (Interruption in CPR should be < 5 seconds, when placing LUCAS). Ensure I-Gel, ITD (ResQPOD), ETCO2 adapter (if readily available) are in place. Perform Rhythm Check as needed. Start the Timer on EleGARD (Button 2) and continue CPR. Begin elevating the head when timer begins to flash after two (2) minutes. (Button 3). Once elevation complete, leave in elevated position. Frequently monitor LUCAS to ensure correct positioning. Mark the correct placement on the chest with a permanent marker or pen. Consider dedicating a person to this task. Check to make sure all airway devices (I-Gel, ResQPOD, filter, ETCO2 monitor) are secure after head elevation. Page | 2 REV. 08/2022 GREENACRES FIRE RESCUE PROCEDURES FOR ELEGARD – ELEVATED CPR ▪ If initial rhythm is not shockable, continue working the cardiac arrest on the scene with the EleGARD and LUCAS device in place for a minimum of thirty (30) minutes (or until ROSC) before deciding next steps. Provide Adequate, Appropriately Timed Ventilations • • • Attach ResQPOD to I-Gel as soon as chest compressions begin. Attach ETCO2 filter line above the ResQPOD, between the ResQPOD and the BVM. Continually reassess for proper airway placement, consider ETT if appropriate. In most cases, a properly sized I-Gel is the preferred airway. Targeted Treatment and Appropriately Timed Medications • • • • Ensure cardiac monitor has been placed and rhythm has been identified. May verify cardiac activity with ultrasound to rule out tamponade (if available). Initiate IV/IO for medication administration. Recording the time that a medication is given is of paramount importance, so that medications are being given at the appropriate interval. The team leader should be responsible for this task, unless delegated to another team member. Reassess rhythm every two (2) minutes limiting CPR interruption to < 5 seconds. Only reassess pulse if rhythm change is noted and spike/change in the ETCO2 reading. VFIB / VTACH: • If initial rhythm is identified as shockable or VF/VT, follow Cardiac Arrest Standing Orders and Protocol. ASYSTOLE / PEA: • If initial rhythm is identified as Asystole / PEA, follow Cardiac Arrest Standing Orders and Protocol. Utilization of a Post ROSC Care • • • If ROSC occurs, follow Post Resuscitation Protocol. Post arrest ROSC patients often re-arrest. Watch for this. Transport to the most appropriate ER. Decision Point • • If ROSC does not occur after a minimum of thirty (30) minutes on scene time, decide whether patient meets criteria for ceasing resuscitation or prepare for transport. If deemed appropriate, resuscitation may be terminated following Standing Orders. o Utilize EtCO2 reading of less than ten (10) mmHg for longer than ten (10) minutes and ultrasound (if available) as additional data points. Page | 3 REV. 08/2022 GREENACRES FIRE RESCUE PROCEDURES FOR ELEGARD – ELEVATED CPR • Ensure a plan is in place for evacuation and coordination with team before beginning patient movement and transport. Pearls and Pitfalls • • • • • • Transport late term gravid pregnant and hypothermic cardiac arrests expeditiously following Standing Orders. Consider the possibility of hyperkalemia in patients on dialysis or renal failure. The optimal airway technique for cardiac arrest is unknown and is likely to depend on the skills of the operator, the anticipated prehospital time, and patient-dependent factors, therefore it is acceptable to place an I-Gel as the first go-to airway if deemed appropriate. This is preferred over multiple time-consuming attempts at intubation while no compressions are occurring. However, as resources allow, consider transition to ET tube after initial actions have been completed. A note on CPR induced consciousness: evidence shows a 1% rate of CPR induced consciousness in cases of high perfusion CPR. Should this occur consider sedation of patient with Ketamine. Post arrest ROSC patients often re-arrest. Watch for this as one or more additional shocks may be needed. Keep Critical Triangle Clear of all secondary equipment (other than EleGARD, LUCAS, Zoll Monitor) until equipment is needed later in the call, also keep family and secondary rescuers out of this critical triangle. Standing Procedures for EleGARD, Inclusion/ Exclusion Criteria: • • • • • Pt is a FULL CODE. Suspected cardiac cause of arrest. Body habitus allows LUCAS CPR (must be used for transport). Patient does not fit into EleGARD Equipment. Not for use in Hemorrhagic Arrest or Blunt Trauma Arrest (Blunt Trauma is due to possible internal bleeding). Quality Assurance • • • • • • Continuous compressions are performed with minimal interruptions. Adherence to the protocol workflow. Upload of data with each ePCR with accurate and complete charting is required. Ensure transport is fluent and planned out before patient movement. Post Call Review should be completed to document areas that went well and to see if improvements could be made in other areas. Placement of EleGARD within four (4) minutes of arrival at patient. Page | 4 REV. 08/2022