ACLS Flashcards
4 elements of integrated system of care
- Structure: people, education, equipment
- Process: protocols, policies, procedures
- System: programs, organizations, culture
- Patient Outcome: balance of satisfaction, safety, quality
Factors associated w/ improved survival in pts with cardiac arrest:
- training HCP to be more knowledgeable about what improves survival rates
- proactive planning & simulation of cardiac arrest to provide opportunity for HCP to practice/improve responding to cardiac arrest
- rapidly recognizing sudden cardiac arrest
- immediately providing high quality CPR
- providing early defibrilation
- providing goal oriented, time sensitive, post-cardiac arrest care
Chain of Survival
- early recognition & prevention
- activation of emergency response
- high quality CPR
- defibrillation
- post-cardiac arrest care
- recovery
Rapid response system
purpose of a rapid response team (RRT) or medical emergency team (MET) is to improve patient outcomes by identifying & treating early clinical deterioration.
* event detection & response triggering arm
* planned response arm (such as RRT/MET)
* quality monitoring
* administrative support
Signs of clinical deterioration for adult patients:
8
- airway compromise
- RR < 6/min or > 30/min
- HR < 40/min or > 140/min
- Systolic BP: < 90mmHg
- Symptomatic Hypertension
- Unexpected decrease in LOC
- Unexplained agitation
- Seizure
How does rapid response prevent in-hospital cardiac arrests?
- best way to improve survival chance is to prevent IHCA from ever occuring
- teams rapidly assess and intervene when patients have abnormal vital signs which reduces # of IHCAs and improves morbidity & mortality
Impact of RRTs/METs
ideal composition of METs and RRTs not known, but many published before/after studies have reported a drop in rate of cardiac arrests after these teams intervene. Findings:
* reduced unplanned emergency transfers to the ICU
* decreased ICU and total hospital length of stay
* reduced postoperative morbidity and mortality rates
* improved rates of survival from cardiac arrest
Key components of an effective high performance team
Timing
* time to first compression
* time to first shock
* CCF ideally greater than 80%
* minimizing preshock pause
* early EMS response time
Quality
* rate, depth, and recoil
* minimizing interrupt
* switching compressors
* avoiding excessive ventilation
* use of feedback device
Coordination
* team members working together, proficient in their roles
Administration
* leadership
* measurement
* continuous quality improvement
* number of code team members
Key Components of an Effective High Performance Team
Successful high-performance teams not only have medical expertise and mastery of resuscitation skills but also demonstrate effective communication & team dynamics
One of the measures of a high-performance team is the ability to achieve performance metrics and a high chest compression fraction (CCF). You can only achieve high CCF by minimizing pauses during high quality CPR.
* The Resuscitation Outcomes Consortium (ROC) trials showed an 11% increase in CCF is roughly equal to a 10% increase in survival.
* Pauses can occur during intubation, rhythm analysis, pulse checks, compressor switches, and defibrillation.
Recommendations
* Hover over the chest: whenever compressions are paused, compressors should hover over the chest (not touching it) to prepare to resume compressions
* Before pausing compressions: 15s before pausing compressions at the end of each 2 min cycle, high-performance teams should check for a pulse, pre-charge the defibrillator, and be prepared to deliver a shock in 10s or less.
* Switch Compressors: switch with the second compressor coming in from behind the first (this allows the 2nd to have the same view of the team). Seamless transitions = switching every 2 minutes
* Real Time Feedback Devices: practice w/ real time feedback devices during CPR
Roles of High Performance Team Members
Team Leader
* organize group
* monitor individual performance, back up team members
* train/coach, facilitate understanding
* models excellent team behavior
* focuses on comprehensive patient care
Team Member Roles
* proficient in performing the skills in their scope of practice
* clear about role assignments
* prepared to fulfill their role responsibilities
* well practiced in resuscitation skills
* knowledgeable about algorithms
* committed to success
CPR Coach
* coordinate initiation of CPR
* coach team members to improve quality of chest compressions
* coach team members to improve quality of ventilations
Elements of Effective Team Dynamics
Clear Roles/Responsibilities
- Leader: clearly define all team member roles in clinical setting; distribute tasks evenly to all available team members
- Members: seek out & perform clearly defined tasks appropriate to their abilities; ask for new task/role if assignment is beyond their level of expertise; take only assignments w/in level of expertise
Elements of Effective Team Dynamics
knowing limitations
- Leaders + Members: call for assistance early rather than waiting until pt deteriorates; seek advice from more experienced personnel when pt’s condiiton worsens despite primary tx; allow others to carry out assigned tasks (esp if task is essential to tx)
- Members: seek advice from more experienced personnel before starting an unfamiliar tx; accept assistance from others when it is readily available
elements of effective team dynamics
- Leaders: ask that a different intervention be started if it has a higher priority; reassign a team member who is trying to function beyond their skill
- Members: suggest alternative drug/dose confidently; question colleague who is going to make an error; intervene if drug admin is incorrect
What to Communicate
knowledge sharing
sharing info is critical to effective team performance
* Leader: encourage info sharing, ask for suggestions about interventions, differential diagnoses, and possible overlooked tx, look for clinical signs that are relevant to tx
* Members: share info w/ each other, accept info that will improve their roles
what to communicate
summarizing & re-evaluating
an essential role of the team leader is monitoring & re-evaluating interventions, assessment findings, and pt status.
* leaders: continuously re-visit decisions about ddx; maintain ongoing record of tx and pt’s response; change tx strategy if new info supports it; inform arriving personnel of the current status & plans for further action
* Members: note significant changes in pt’s clinical condition; increase monitoring pt’s condition deteriorates
how to communicate
closed loop communication
closed loop communication is process of verifying that the message sent was received as intended. It also verifies that assigned tasks have been completed.
1. give message, order, or assignment to team member
2. request clear response/eye contact to ensure that he/she understood the message
3. confirm that the team member completed the task before you assign them another task
- Members: after receiving a task, close loop by informing the task leader when the task begins/ends; give drugs only after verbally confirming the order w/ the team leader
- Leaders: assign tasks via closed-loop communication; assign additional tasks to a team member only after receiving confirmation of a completed assignment
how to communicate
clear messages
clear messages mean concise communication spoken w/ distinctive speech in a controlled voice. All HCP should deliver clear messages calmly and directly. Distinct, concise messages are crucial for clear communication because unclear communication can delay tx or cause med errors.
- Leaders: encourage all team members to speak clearly & use complete sentences
- Members + Leaders: repeat orders & question them if doubt exists; be careful not to mumble/yell/scream/shout; ensure only 1 person talks at a time
how to communicate
mutual respect
speak to each other in a professional manner, regardless of scope of practice/expertise. Resuscitation events are stressful and emotions can run high.
- Leaders: acknowledge completed assignments
- Both: listen to others; speak in a friendly way; avoid displaying frustration/aggression; understand that when one person raises their voice, others will respond similarly; try not to confuse directive behavior w/ aggression
communicating
the debrief
debrief as a team to improve subsequent performance
components of high quality CPR
- compress chest hard & fast at least 2in at a rate of 100-120/min (30:2 ratio)
- allow chest to completely recoil after each compression
- minimize interruption in compressions
- switch compressors about every 2 min or earlier if fatigued (switch in < 5 min)
- avoid excessive ventilation
high-quality cpr
minimizing interruptions
when you stop compressions, blood flow to the brain/heart stops, so you should minimize interruptions
* AVOID: prolonged rhythm analysis, frequent/inappropriate pulse checks, prolonged ventilation, unnecessary movement of pt
* CCF= chest compression fraction; proportion of time during cardiac arrest when the rescuer is performing compressions (minimal is 60%; ideal is > 80%)
CCF = actual chest compression time/total code tide
high quality CPR
tailoring sequence of rescue actions
guidelines recommend that CHP tailor the sequence of rescue actions based on presumed etiology of the arrest. ACLS providers can choose the best approach for their high-performance team to minimize interruptions in chest compression & improve CCF including:
* continuous chest compressions w/ asynch ventilation Q6 s with use of bag mask device
* compression only CPR in the first few min after arrest
Coronary Perfusion Pressure (CPP)
crucial to minimize interruptions in compressions to maintain adequate CPP
* CPP = aortic diastolic pressure - right atrial diastolic pressure
Info
* during CRP, CPP correlates w/ myocardial blood flow and ROSC
* when HCP interrupt chest compressions, coronary perfusion pressure decreases dramatically and remains low until compressions are resumed
* the higher the coronary perfusion pressure during CPR, the higher the chances of survival for patients
* surein a patient w/ an arterial line, a reasonable surrogate for CPP is arterial relaxation or diastolic pressure
Interruptions in chest compressions
quantitative waveform capnography
because CPP or arterial diastolic pressure measurements are not readily available during a resuscitation attempt, HCP can monitor CPR quality w/ quantitative waveform capnography using advanced airway in place of a bag-masked device.
* this used ETCO2 to estimate tissue perfusion and the quality of chest compressions
defib + survival
early defibrillation
the interval from collapse to defibrillation is one of the most important determinants of survival from cardiac arrest (early defib = vital)
* common rhythm in out-of hospital witnessed sudden cardiac arrest= v fib
* pulseless ventricular tachycardia (pVT) rapidly can deteriorate to VF (heart quivers & does not pump blood)
* electrical defibrillation is most effective tx of VF & pVT
* probability of successful defibrillation decreases over time
* VF deteriorates to asystole if no tx
Defib + survival
minimizing interruptions in compressions during defibrillation
- AHA does not recommend continued use of an AED or automatic mode when manual defibrillator is available & providers can adequately interpret rhythms
- rhythm analysis & shock admin w/ AED can prolong interruptions in chest compressions
- while manual defib is charging, resume CPR (shortens interval between last compression + shock, even a few seconds improves success)
- return to CPR as soon as shock is delivered
Defib + Survival
safe defibrillation
defibrillation should take fewer than 5s
* “CLEAR. SHOCKING”: check to make sure everyone is clear of contact w/ patient, stretcher, or other equipment; make visual check to ensure that no one is touching pt or stretcher; make sure O2 not flowing across pt’s chest
* when pressing the shock button, the defib operator should face the patient, not the machine. This helps to ensure coordination w/ the chest compressor & to verify that no one has resumed contact w/ the patient
systematic approach
for optimal care, HCP use systematic approach to assess & tx acutely ill or injured patients. Not only does the systematic approach allow a standardized emthod for evaluating pts, it reduces the chances of missing/overlooking important signs and sx that should be considered.
Components
* initial impression (visualization, scene safety)
* BLS assessment
* Primary Assessment (ABCDE)
* Secondary Assessment (SAMPLE, H’s and T’s)
Systematic Approach
Initial Impression
- rapidly survey scene to determine if it is safe/no threat to provider
- then determine patient’s LOC
- if unconscious: BLS assessment
- if conscious: primary assessment –> secondary assessment
BLS Assessment
- early CPR w/ basic airway management & defibrillation (but not advanced airway techniques or drug administration)
- by using BLS assessment, any HCP can support or restore effective oxygenation, ventilation, and circulation until patient achieves ROSC or advanced providers intervene.
Tailoring Sequence of Rescue Actions
* single rescuers may tailor the sequence of resuce actions to the most likely cause of arrest
STEPS
1. check for responsiveness (tap/shout “are you ok?”)
2. shout for nearby help/activate emergency response system & get the AED/defib
3. check for breathing/pulse (check for absent/abnormal breathing (assess for at least 5s max 10s), feel for a pulse 5-10s, should do them simultaneously; IF you find a pulse do rescue breaths Q6s and check pulse Q2 min; no breath = CPR & begin w/ chest compressions
4. defib (check for shockable rhythm, provide as advised)
