Cardiac Arrest Education

Tigger

Tigger

Dodges Pucks
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If you had an hour to teach some cardiac arrest management strategies, what message would you want to get out there?

I'm tired of dry and bland CEs, so I volunteered to develop a cardiac arrest training. I also think the "provider discretion" that we allow when it comes to individual preferences when running arrests probably needs to go away. ACLS is an algorithm, but it a) does not provide a detailed timeline and b) does not often mesh very well with systems guidelines.

We talk about "high performance CPR," but what is the right way to teach it?
 
In my opinion, everyone knows what needs to be done. We've all been hearing the same crap for years now. It's always the same thing. I don't understand why it goes out the window when we actually do an arrest. Perhaps spending a class just doing multiple drills with immediate feedback would be best? Honest feedback as well. Not the "You did good" and that's it.

Common mistakes I see in arrest is stopping CPR too much. They'll stop for pulse checks or rhythm check. People check for a pulse or rhythm waaaay too frequently. They'll sometimes stop for intubation which is cringe. They'll stop to move the patient. They'll load and go, transport to the hospital right away. They'll be too slow getting the Autopulse or Lucas on. One call, the Lucas was not doing compression, it has a loud beep, and a red light. Instead of doing compressions, the firefighters were trying troubleshoot the Lucas.

Poor poor poor bag-mask ventilation. Almost always been poor which is why I personally prefer to intubate. A patient could literally have an occluded airway and firefighters will still report good compliance, rise and fall, and say we can stick to BLS.

That's the other thing, not just with cardiac arrest, but people go through the motions as if they were in school. If you say it, it happened. You pleural decompress, you heard air go out.... You intubate, you got breath sounds with no gastric sounds. We do the same thing on actual calls. People will do things as if saying it or later documenting it makes it true. We need people to actually honestly evaluate what they are doing.

An alternative to H's and T's would be good. I came up with my own bad mnemonic for it. H's and T's is a little bit too much to remember I feel. I feel like people, including myself, struggle with it. Like I said, we verbalize it without actually evaluating or treating patients for it as well.
 
For what it’s worth, I teach pit crew CPR with scenarios. I have a tarp made that has everyone’s position. It reinforces where crewmembers should be in relation to the patient and reinforces moving the patient into an area where there’s room to work. I also video them and we can go back and debrief. People seem to appreciate working a cardiac arrest when the feedback is very positive and the team can critique all together.

I think the comment above “everyone knows what to do“ is really spot on. The problem is, not everyone knows what to do with everyone else. Teaching cardiac arrest resuscitation as a team sport is probably the most vital thing we can do. I also agree with incorporating some distractors. These are things that provide critical thinking for the lead paramedic.
 
Tigger said:
If you had an hour to teach some cardiac arrest management strategies, what message would you want to get out there?

I'm tired of dry and bland CEs, so I volunteered to develop a cardiac arrest training. I also think the "provider discretion" that we allow when it comes to individual preferences when running arrests probably needs to go away. ACLS is an algorithm, but it a) does not provide a detailed timeline and b) does not often mesh very well with systems guidelines.

We talk about "high performance CPR," but what is the right way to teach it?
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Not rushing to intubate (unless needed). Prepping pressors once ROSC is achieved. Charging the defib during compressions. The basics of CPP and the effect of prolonged pauses. Airway management tools like SALAD. Management and organization skills (not having long pauses, keeping your work space clean, having things prepared for the next step, etc)
 
StCEMT said:
Not rushing to intubate (unless needed). Prepping pressors once ROSC is achieved. Charging the defib during compressions. The basics of CPP and the effect of prolonged pauses. Airway management tools like SALAD. Management and organization skills (not having long pauses, keeping your work space clean, having things prepared for the next step, etc)
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I think there’s also some significant value in doing some independent task training. For example, does everyone know the steps to putting together push dose epi? Of course, it’s simple easy until you’re in a position where you’re task saturated. Same thing with drawing up amiodarone. It’s such a simple thing, but if you want to add a great distractor, shake the vial before you give it to somebody.

A great way to convince someone that task saturation is real is to video the steps they take to start an IV and then video the steps they take to drill an IO. Once I did this, I convinced almost everyone that taking the 20 extra steps to start an IV took their eye of the ball during a cardiac arrest resuscitation, when we needed to get epi on board early

These are all things that can add a sense of realism to a cardiac arrest resuscitation training and make for great teaching points
 
We have the fancy (expensive) feedback mannequins that show a live look at compression depth, if you're allowing full chest recoil, and rate, even ventilations if they're going in at all, too much/too little. We're required to run through a drill on the mannequins with proctor from the Training Bureau at least once a year.

Apparently the downloaded data from our AED can tell our Medical Director how well we're doing on the Chest Compression Fraction on actual incidents.
 
Has anyone done SALAD on a real patient? I'm not a fan. Do you guys like it? To me, it just seems to take up space, add clutter, and isn't very effective in my own experience. I also believe it leads to over confidence with using video laryngoscopy when direct probably would've been the safer better route. At the same time, when fluids do end up on the camera screen, I feel like people give up too quickly, pulling it out immediately or stop being methodical with the laryngoscope. They just start massaging the esophagus, usually too deep with the laryngoscope, if the decide proceed to with a covered camera screen.

For the record, I have the Ducanto suction. I practice SALAD almost every single shift I work. I could be practicing it wrong which could be a reason why I don't find it very wrong. Doing it for 200 years doesn't mean you are doing it right for 200 years. I have tried it on multiple patients and find it worse on actual patients than mannequin. Actual patients seem to have smaller airway than our mannequins so the clutter is worse.
 
Aprz said:
In my opinion, everyone knows what needs to be done. We've all been hearing the same crap for years now. It's always the same thing. I don't understand why it goes out the window when we actually do an arrest. Perhaps spending a class just doing multiple drills with immediate feedback would be best? Honest feedback as well. Not the "You did good" and that's it.
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You hit it perfectly. It's so easy to talk the talk and yet I still frequently participate in arrests that are not smooth at all. My present plan is to run through a "standard" timeline/algorithm and then have the crews do it and see how it goes.
Aprz said:
Has anyone done SALAD on a real patient? I'm not a fan. Do you guys like it? To me, it just seems to take up space, add clutter, and isn't very effective in my own experience. I also believe it leads to over confidence with using video laryngoscopy when direct probably would've been the safer better route. At the same time, when fluids do end up on the camera screen, I feel like people give up too quickly, pulling it out immediately or stop being methodical with the laryngoscope. They just start massaging the esophagus, usually too deep with the laryngoscope, if the decide proceed to with a covered camera screen.

For the record, I have the Ducanto suction. I practice SALAD almost every single shift I work. I could be practicing it wrong which could be a reason why I don't find it very wrong. Doing it for 200 years doesn't mean you are doing it right for 200 years. I have tried it on multiple patients and find it worse on actual patients than mannequin. Actual patients seem to have smaller airway than our mannequins so the clutter is worse.
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Yes and I do like it. One thing that we don't emphasize enough when teaching intubation during cardiac arrests is position the head in such a way that it's secured. Too often I see someones head moving during compressions and that makes intubation very difficult and doubly so with SALAD when you're trying to aim the suction at a moving target. Get some towels or blankets and cradle the head.

I also find it's a very deliberate maneuver that you have to move slow with. To help me with this, I'll stick the ducanto into the mouth not particularly far, and then place the McGrath just deep enough to visualize the suction. At this point I'm barely down the tongue, and then I move very slowly into the oropharynx. I also like to put the suction unit on the left of the patient, which at first seems annoying as the suction is crossing over your hand as you guide it. The plus is that if you want to wedge into the corner of the mouth after placing the Ducanto in the esophagus, nothing will be in your way when you pass the tube.
 
Aprz said:
Has anyone done SALAD on a real patient? I'm not a fan. Do you guys like it? To me, it just seems to take up space, add clutter, and isn't very effective in my own experience. I also believe it leads to over confidence with using video laryngoscopy when direct probably would've been the safer better route. At the same time, when fluids do end up on the camera screen, I feel like people give up too quickly, pulling it out immediately or stop being methodical with the laryngoscope. They just start massaging the esophagus, usually too deep with the laryngoscope, if the decide proceed to with a covered camera screen.

For the record, I have the Ducanto suction. I practice SALAD almost every single shift I work. I could be practicing it wrong which could be a reason why I don't find it very wrong. Doing it for 200 years doesn't mean you are doing it right for 200 years. I have tried it on multiple patients and find it worse on actual patients than mannequin. Actual patients seem to have smaller airway than our mannequins so the clutter is worse.
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Ive also used the SALAD technique on real patients and it’s a life saver. If you do it right, it keeps the distal end of the blade/camera out of the muck and will continue to evacuate effluent when you park the catheter in the esophagus.
 
I wonder if maybe brand of video laryngoscope matters? I cannot imagine doing it with King Vision channel blade. Can barely fit that in the mouth by itself. The only video laryngoscope I've tried it on is CMAC. I tried MacGrath on cadavers, liked it, felt lighter to me, but I guess CMAC is lighter (doesn't feel it). CMAC to me seems bigger. My go to size is usually size 3 blade just like I'd do with with direct. Currently do not put pillows under the head for sniffing. We just elevated the head using the gurney. I suction the mouth, dig the ducanto deep, then intubate. Just not my groove I guess.
 
I'll admit that I usually do a modified version. I usually don't park the suction in the esophagus since it's almost never active vomiting or bleeding. The progression and visualization steps I do follow though. The rare occasion of an active contamination, then I'll do a true SALAD. I don't think it's always necessary to follow to the letter, but the foundational points are.
 
Oh and on the note of channeled blades, it's not easy and requires a bit of modification, but it can be done. My full time job has air traqs and I've practiced using that before.
 
One thing that was mentioned above but that I think is worth repeating is immediate post-ROSC care. I have seen too many times where crews get through the arrest, get ROSC, then just sit there and don’t really know what to do next and watch as the patient re-arrests. 1 round, 1 epi, ROSC, repeat. This was probably more of a problem a few years ago where in less…aggressive…areas of the country, the only vasoactive medics had in their drug box was dopamine, but even if that’s all you have, starting a dopamine drip is better than doing nothing. Striking that balance between trying to temporize hemodynamics and setting up a drip in stressful conditions (again, if in local protocols) versus expediting rapid transport is worthwhile, IMO.
 
Certainly will be touching on ROSC care. Someone smarter than me coined the phrase “ROSC timeout” which I love. No movement for at least two minutes. During this time someone is purely dedicated to a continuous mechanical pulse check, a 12 lead is acquired, an epi drip is made, and if possible secondary access is obtained. Once all this happens, if ROSC is sustained we transport.
 
Tigger said:
Certainly will be touching on ROSC care. Someone smarter than me coined the phrase “ROSC timeout” which I love. No movement for at least two minutes. During this time someone is purely dedicated to a continuous mechanical pulse check, a 12 lead is acquired, an epi drip is made, and if possible secondary access is obtained. Once all this happens, if ROSC is sustained we transport.
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we sit for 10 minutes post ROSC
 
MonkeyArrow said:
Don’t like that as a general rule. Why?
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It’s a suggestion in our protocols. ROSC patients are vulnerable in that periarrest period, so a timeout allows for some hemodynamic stabilization to happen and gives everyone a few minutes to calm down a bit. Gives you a chance to methodically package and untangle, get your gear set up comfortably in the ambulance and make your way calmly to the hospital.
it’s not a hard and fast rule, but we like to calmly package and be ready for a rearrest.

B12B29E1-67F9-4497-A07B-DF56836D23FE.jpeg
 
NomadicMedic said:
It’s a suggestion in our protocols. ROSC patients are vulnerable in that periarrest period, so a timeout allows for some hemodynamic stabilization to happen and gives everyone a few minutes to calm down a bit. Gives you a chance to methodically package and untangle, get your gear set up comfortably in the ambulance and make your way calmly to the hospital.
it’s not a hard and fast rule, but we like to calmly package and be ready for a rearrest.

View attachment 5427
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Nice to see it’s a guideline, and not a rule. My concern in delaying transport is cases where further field interventions wouldn’t help to stabilize the patient. First example that comes into my mind is a STEMI, where reperfusion is really the only thing that will stabilize the patient or help prevent further re-arrest, but one could conceivably think of other cases like massive PE or the pregnant patient. Of course, you’d hope your field providers would be able to use critical thinking and good judgement to recognize these situations, but I’m jaded…
 
The systolic > 120 is a surprise to me...I'd guess there's evidence for that, but driving the pressure to 120 if you have a MAP of 70 or better? Explain that?
 
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