fact or fiction

[ffemt101986]

As a newer paramedic i have what may be a dumb question. I have been on a few full arrests recently where my older paramedic partner seems to think that we are able to judge the quality of chest compressions by watching the waveform on the cardiac monitor. At first i thought that was one of those tricks you learn over time but the more i think about it it doesnt make sense. The monitor measures electrical activity of the myocardium. CPR is simply a mechanical function. That being said is there a way to effectively judge quality of chest compressions other than ETCo2? I may be way out in left field here and wont have my feelings hurt if i get critical responses. I want to be squared away without comi g off like im questiong my FTO.

 

[VFlutter]

No, the EKG artifact does not tell you anything about the quality of compressions. When doing compressions you will usually see a rhythmic waveform type pattern. Maybe he is assuming that the rate and appearance will tell you something. While I guess it could tell you about tempo it will not give you any objective data about quality.

I am lucky that many of my patients who arrest get an arterial line. Best way to visualize the effectiveness of your compressions.

 

[NomadicMedic]

You CAN assess the quality of compressions with a puck that is placed on the chest. Some monitors use this to determine depth and rate and provide feedback during the code.

The Physio "code stat" software can be used after the arrest to critique a code. It provides a breakdown of "on chest time" and the compression fraction. It uses a measurement of impedance between the defibrillator pads to assess compression quality. Reviewing a code that utilized the LUCAS and short assessment/shock pauses is amazing to see.

But you're correct. The CPR artifact doesn't accurately reflect quality of compressions.

 

[tchristifulli]

Prehospital Capnography is the best way in the field. A reading of 15-20 is where you want to be when doing compressions . The patients down time plays a factor in this though.

 

[Christopher]

As a newer paramedic i have what may be a dumb question. I have been on a few full arrests recently where my older paramedic partner seems to think that we are able to judge the quality of chest compressions by watching the waveform on the cardiac monitor. At first i thought that was one of those tricks you learn over time but the more i think about it it doesnt make sense. The monitor measures electrical activity of the myocardium. CPR is simply a mechanical function. That being said is there a way to effectively judge quality of chest compressions other than ETCo2? I may be way out in left field here and wont have my feelings hurt if i get critical responses. I want to be squared away without comi g off like im questiong my FTO.

Depends on which waveform you're discussing. The monitored ECG via the pads will have a "waveform" due to the changing impedance in the chest wall from the chest compressions.

So yes, while CPR is mechanical, it does have an actual effect on the electrical monitoring.

Certain cardiac monitors will extract the impedance channel and produce a strip showing compressions. All you can glean from this is the rate and presence, but not depth/effectiveness.

(side note: ALL monitors and AED's look at the impedance channel in order to determine how to adjust the timing, duration, and amplitude of their biphasic shocks)

In order to judge effectiveness you need:
1. Rate
2. Depth
3. Recoil (combine with depth to monitor "travel distance")

Philips and Zoll use accelerometers akin to the devices found in your cell phone to measure these three components (it monitors relative depth/recoil). Physio-Control uses magnetic fields to determine exact travel distances of their device.

Beyond ETCO2:

If you're discussing the SpO2 waveform (plethysmograph), then perhaps you are directly measuring the effectiveness.

I'd encourage you to apply an NIBP cuff to your next cardiac arrest and note trends in the MAP to measure effectiveness.

Prehospital Capnography is the best way in the field. A reading of 15-20 is where you want to be when doing compressions . The patients down time plays a factor in this though.

We're pretty disappointed if we're under 20 mmHg, and routinely have ETCO2 in the low 30's during metronome and real-time feedback guided continuous compressions.

 

[vasile]

The EtCO2 I think is the best marker for ventilations and quality of your CPR.

 

[SDmedic]

I'd be weary using only one to judge my quality. Use a number of things, including etco2.

 

[mycrofft]

Does analytic software for the pucks take into account the patient's size, skeletal resistance etc?

I teach my CPR students the standards, but I also make it very clear that SCIENTIFICALLY the standard is 1/3 the distance form the sternum to the floor. (And even THAT science is sort of a rule of thumb).

CPR for Woody Allen and for Hulk Hogan would obviously require different pressure and tend to have different durations for compression and especially recoil.

Yeah, before we were around EKG's all the time we would try to palp a femoral pulse to gauge CPR efficacy. Just about as useless.

 

[Mariemt]

Press until you hear the click noise silly!

I always hated doing cpr on the foam dummies and then the dummies that clicked.
I was finally told, you will break ribs.

 

[FiremanMike]

Does analytic software for the pucks take into account the patient's size, skeletal resistance etc?

I teach my CPR students the standards, but I also make it very clear that SCIENTIFICALLY the standard is 1/3 the distance form the sternum to the floor. (And even THAT science is sort of a rule of thumb).

CPR for Woody Allen and for Hulk Hogan would obviously require different pressure and tend to have different durations for compression and especially recoil.

Yeah, before we were around EKG's all the time we would try to palp a femoral pulse to gauge CPR efficacy. Just about as useless.

We had the pucks for several years and didn't care for them, erroneous error messages, way more loud noises on scene, inconsistent, etc. I'm curious if anyone has continued to use them and seen useful upgrades that make them better?

We use the zoll auto pulse now, absolutely wonderful piece of equipment.

 

[Mariemt]

We had the pucks for several years and didn't care for them, erroneous error messages, way more loud noises on scene, inconsistent, etc. I'm curious if anyone has continued to use them and seen useful upgrades that make them better?

We use the zoll auto pulse now, absolutely wonderful piece of equipment.

We also have a Zoll. It is awesome. If course we have to start manually and get it set up but it is sure nice for freeing up hands and keeping quality up

 

[ffemt101986]

Correct me if I'm wrong, but I would see the puck as somewhat of a liability issue. If the family is standing near by and is constantly hearing the machine correct the way your performing compressions it could cause you issues down the road. We use Philips MRX and it has the puck capability but I cant say I've ever used it.

 

[Medic Tim]

Correct me if I'm wrong, but I would see the puck as somewhat of a liability issue. If the family is standing near by and is constantly hearing the machine correct the way your performing compressions it could cause you issues down the road. We use Philips MRX and it has the puck capability but I cant say I've ever used it.

the newer update and puck for the mrx gives visual cues on the puck itself before an auditory one. This makes it much quieter and the person doing compressions has a good view of it. I am a fan of them. I hated them at first but have come around.

 

[ffemt101986]

ill definitely look into that. Thank you

 

[Christopher]

We had the pucks for several years and didn't care for them, erroneous error messages, way more loud noises on scene, inconsistent, etc. I'm curious if anyone has continued to use them and seen useful upgrades that make them better?

We use feedback on our X-Series and really like it. From a QA perspective I love it (from a code back in July):

We also use separate metronomes to guide our compressions.

We use the zoll auto pulse now, absolutely wonderful piece of equipment.

The rate seems too slow and does not appear to change outcomes. Tough to justify the cost when we've got firefighters streaming out of every orifice on a cardiac arrest.

 

[Christopher]

Correct me if I'm wrong, but I would see the puck as somewhat of a liability issue. If the family is standing near by and is constantly hearing the machine correct the way your performing compressions it could cause you issues down the road.

There is 0 liability issue. None. Zilch. Nada.

If you coach people doing CPR during codes, does that make you liable?

If you coach people intubating / placing BIAD's during codes, does that make you liable?

If you coach people starting IV's, pushing medications, reading 3-Leads, reading 12-Leads, using glucometers, using blood pressure cuffs, etc; does coaching anyone on a call make you any more liable than you already are?

You're more liable when you run a 12-Lead and interpret it as "normal". I'll bet you do that far more often than you would use real time CPR feedback technology.

Please don't ignore something as important as CPR feedback because you're worried it'll make you look bad to the family. (If it is telling you to push harder...you should push harder)

If you don't do real time or QA/QI feedback on your CPR, you're probably doing it wrong.

How do I know this? Because you don't know how good you're doing CPR (and you have no objective means of showing me). Because we didn't know how good we were doing CPR.

We do now.

We use Philips MRX and it has the puck capability but I cant say I've ever used it.

Use it. Use it on every code.

You'll notice you're not doing things as well as you should.

You'll improve.

Your numbers will go up.

Way up.

 

[Medic Tim]

There is 0 liability issue. None. Zilch. Nada.

If you coach people doing CPR during codes, does that make you liable?

If you coach people intubating / placing BIAD's during codes, does that make you liable?

If you coach people starting IV's, pushing medications, reading 3-Leads, reading 12-Leads, using glucometers, using blood pressure cuffs, etc; does coaching anyone on a call make you any more liable than you already are?

You're more liable when you run a 12-Lead and interpret it as "normal". I'll bet you do that far more often than you would use real time CPR feedback technology.

Please don't ignore something as important as CPR feedback because you're worried it'll make you look bad to the family. (If it is telling you to push harder...you should push harder)

If you don't do real time or QA/QI feedback on your CPR, you're probably doing it wrong.

How do I know this? Because you don't know how good you're doing CPR (and you have no objective means of showing me). Because we didn't know how good we were doing CPR.

We do now.



Use it. Use it on every code.

You'll notice you're not doing things as well as you should.

You'll improve.

Your numbers will go up.

Way up.

This ^^^

my current job used lp 12s... I miss the cpr puck.

 

[medicdan]

We use feedback on our X-Series and really like it. From a QA perspective I love it (from a code back in July):

We also use separate metronomes to guide our compressions.



The rate seems too slow and does not appear to change outcomes. Tough to justify the cost when we've got firefighters streaming out of every orifice on a cardiac arrest.

My understanding is that the AutoPulse doesn't need to compress as fast because its compressions are over the entire chest cavity, so are thought to be more effective. Firefighters are great, but not as consistent as mechanical services, which also allow you to compress on stairs, and during transport if you choose, without compromising rescuer safety.

 

[Christopher]

My understanding is that the AutoPulse doesn't need to compress as fast because its compressions are over the entire chest cavity, so are thought to be more effective. Firefighters are great, but not as consistent as mechanical services, which also allow you to compress on stairs, and during transport if you choose, without compromising rescuer safety.

I can objectively state what our compression quality is:

Since adopting metronomes and guided feedback we have obtained a compression fraction >90% on every code we have run. Every one. Our 90th percentile peri-shock pause is <5 seconds, 99th percentile is <10 seconds.

Since adopting metronomes and guided feedback we are at roughly ~80% compliance with depth (usually on the low side) and ~90% compliance with rate (usually on the high side).

Our one point of failure is a 90th percentile ventilation rate of 14 bpm, which is still way too fast. The data is incomplete as Code Review stopped analyzing ventilation rate after we upgraded our monitors, so I'm missing probably 3-4 months of data. I don't believe we're doing any better in that regard.

Now we have the benefit of being a small department with 100% QA/QI of all EMS calls run, so perhaps other places would not see similar numbers.

In discussions with Zoll we've noted that the puck's are bad at depth measurement after about 4-5 minutes (which the chest gets pliable) and we suspect we're doing better than 80%, probably closer to 90%. Also the pucks get worn out after ~45 minutes of a code.

Survival to discharge with CPC 1/2 has increased five fold by simply focusing on CPR and looking at our CPR in real time.

Studies of the load distributing band have not shown an improvement in any metric, in fact one study showed a decreased survival to discharge with CPC 1/2.

So how can I justify (as a budget guy) adding it to our trucks when I know our current strategy is extremely effective?