advanced resuscitation training - cardiac...
TRANSCRIPT
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Advanced
Resuscitation
Training
DANIEL DAVIS, MDPeople should not die
before they are done living.
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What makes ART unique?• System of care
• Inpatient & prehospital
• Approach to education
• Cognitive psychology
• Curriculum breadth
• Reduce preventable death
• CQI data collection & analytics
• Six sigma-based
• Clinical outcomes
• Consistency across multiple institutions
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System of Care
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CQI
System of Care
Training Technology
Best
Practices Scientific
Evidence
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Screening MonitoringEarly
recognition
Critical care
(including
procedural)
Arrest
resuscitation
Post-arrest
care
End-of-life
issues
Afferents
External
Internal
(Database)
Technology
Efferents
Special
projects
Training
The ART Enchilada
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Screening MonitoringEarly
recognition
Critical care
(including
procedural)
Arrest
resuscitation
Post-arrest
care
End-of-life
issues
Afferents
External
• Scientific evidence
• Past performance
• Other institutions
• Manuals/guides
• Consensus opinion
• Best practices
• Guidelines
• Scientific evidence
• Past performance
• Other institutions
• Manuals/guides
• Consensus opinion
• Best practices
• Guidelines
• Scientific evidence
• Past performance
• Other institutions
• Manuals/guides
• Consensus opinion
• Best practices
• Guidelines
• Scientific evidence
• Past performance
• Other institutions
• Manuals/guides
• Consensus opinion
• Best practices
• Guidelines
• Scientific evidence
• Past performance
• Other institutions
• Manuals/guides
• Consensus opinion
• Best practices
• Guidelines
• Scientific evidence
• Past performance
• Other institutions
• Manuals/guides
• Consensus opinion
• Best practices
• Guidelines
• Scientific evidence
• Past performance
• Other institutions
• Manuals/guides
• Consensus opinion
• Best practices
• Guidelines
Internal
(Database)
• Arrest rates
• Patient diagnoses
• Comorbidities
• Arrest classifications
• Preventability
• Risk-adjusted mortality
• Process issues
• Arrest rates
• Patient diagnoses
• Comorbidities
• Arrest classifications
• Preventability
• Risk-adjusted mortality
• Process issues
• Arrest rates
• Diagnoses/comorbidities
• Arrest classifications
• Rapid response
• Preventability
• Risk-adjusted mortality
• Process issues
• Arrest rates
• Diagnoses/comorbidities
• Arrest classifications
• Preventability
• ICU/ventilator days
• Risk-adjusted mortality
• Process issues
• ROSC
• Survival-to-discharge
• Good neuro outcomes
• Arrest-related deaths
• Arrest classifications
• CPR process measures
• Process issues
• OOHCA survival
• ROSC-to-survival ratio
• Temperature management
• Facilitated PCI
• Neurocritical care
• ICU/ventilator days
• CLBSI/VAP rates
• Code:DNAR mortality
• Rate of 2+ Code Blues
• Advanced directives
• Family discussions
• Palliative care consultation
• Withdrawal
• Organ donation
Technology
• Manual vitals
• Monitor vitals
• Advanced monitoring
• Telemedicine
• Mechanical ventilation
• Circulatory assist devices
• Manual vitals
• Monitor vitals
• Advanced monitoring
• Telemedicine
• Mechanical ventilation
• Circulatory assist devices
• Manual vitals
• Monitor vitals
• MEWS/algorithms
• Advanced monitoring
• Telemedicine
• Mechanical ventilation
• Circulatory assist devices
• Manual vitals
• Monitor vitals
• MEWS/algorithms
• Advanced monitoring
• Telemedicine
• Mechanical ventilation
• Circulatory assist devices
• Monitor
• Defibrillator
• Mechanical compressor
• Circulatory enhancers
• Ventilation devices
• Temperature management
• ECMO
• Advanced monitoring
• Perfusion
• Oxygenation
• Ventilation
• Temperature management
• Percutaneous intervention
• Neurocritical care
• Advanced monitoring
• Computer algorithms
• Prognostication
• Palliative care
• Temperature management
• Compassionate extubation
• Family comfort
Efferents
Special
projects
• Triage/disposition
• Monitoring
• Screening approaches
• Telemedicine
• Hospital configuration
• Alternate care strategies
• Triage/disposition
• Monitoring
• Screening approaches
• Telemedicine
• Hospital configuration
• MEWS/algorithms
• Triage/disposition
• Monitoring
• Rapid response
• Critical care
• Procedures
• Non-arrest codes
• Triage/disposition
• Monitoring
• Screening approaches
• Telemedicine
• Hospital configuration
• Alternate care strategies
• Recognition
• Monitoring
• Equipment
• Code team configuration
• Protocols
• Medications
• Processes
• Advanced monitoring
• Equipment
• Neurocritical care
• Hospital configuration
• Protocols
• Palliative care
• Prognostication
• Monitoring/equipment
• Neurocritical care
• Hospital configuration
• Palliative care
• Prognostication
• Family issues
• Organ donation
Training
• Triage/disposition/monitoring
• ART Matrix
• Perfusion
• Oxygenation
• Ventilation
• Policies/protocols
• Peri-arrest
• Recognition
• Triage/disposition/monitoring
• ART Matrix
• Perfusion
• Oxygenation
• Ventilation
• Policies/protocols
• Peri-arrest
• Recognition
• Triage/disposition/monitoring
• ART Matrix
• Perfusion
• Oxygenation
• Ventilation
• Policies/protocols
• Peri-arrest
• Recognition
• ART Matrix
• Perfusion
• Oxygenation
• Ventilation
• Monitoring
• Procedures
• Peri-arrest
• Recognition
• Recognition
• Compressions
• Ventilations
• Medications
• Monitoring
• Defibrillation
• ROSC
• Rearrest
• ROSC
• POV
• Critical monitoring
• Temperature management
• Facilitated PCI
• Neurocritical care
• Reperfusion strategies
• End-of-life discussions
• Risk stratification
• Prognostication
• Patient/family discussion
• Conflict resolution
• Palliative care
• Ethics
• Organ donation
The ART Enchilada
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Approach to Education
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How We Teach
• Cognitive psychology
• Affective domain
• Conceptual learning
• Vertical perspectivism
• Pattern recognition
• Multiple modalities
• Integrated technology
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Curriculum Breadth
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What We Teach
• Arrest prevention
• The Theory of Everything
• Arrest resuscitation
• CPR Island
• Critical Care
• Integrated Model of Physiology
• Airway Management
• Advanced Airway Resuscitation Training
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ARTNRP
ACLS/BLS
ATLS
PALS
ResuscitationAirway
Procedures
Critical CareVentilator
Specialty
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VF/VT Vagal/block
Hemorrhage/
Hypovolemia
Tamponade/
Tension PTX
SepsisPE CHF
Lung DiseaseTracheostomy
ARDS Obstruction RSI
OtherTBI CVA
Circulatory Dysrhythmic Respiratory Neurologic
CancerImmobilizationCoagulopathy
Obesity
ProcedureCancer
AnticoagulationGI bleed
ICU
InfectionImmunocompromisedLines/catheters/tubes
Elderly/neonateShock
TraumaVentilator
COPD
Known CHFRenal failurePost-event
Lupus
Acute Coronary SyndromeCoronary Artery Disease
Known dysrhythmia
Movement (ICU)Stimulation (ICU)
Toilet Related DeathsHypervagal
TracheostomySecretionsBleeding
Known sleep apneaNarcotics/sedatives
Post-procedureSTOP BANG“Snorking”
Asthma/COPDKnown pulmonary disease
Pulmonary edemaPneumoniaOld/young
Undergoing RSIKnown ARDS
(ICU)
Known TBIPost-craniotomy
Known CVAVasculopathy
Anti-coagulationPost-craniotomy
Brain tumorElevated ICP
AVM
The Theory of Everything
SHOOT
Supine→IVF→Pressors→Blood
Etiology-specific therapy
VAD, ECMO
AIM
Vitals, labs, x-ray, other
SHOOT
Supine→IVF→Meds
Etiology-specific therapy
Pacing, shock
AIM
Exam, vitals, monitor, ECG
SHOOT
Upright→O2→BVM→PAP
Etiology-specific therapy
Intubation, ventilator
AIM
Vitals, labs, x-ray, other
SHOOT
Upright→osmotic→ventilation
Etiology-specific therapy
Burr, ventriculostomy, surgery
AIM
Exam, vitals, ICP, x-ray, other
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Circulatory
Time
SBP
HR
COMPENSATED UNCOMPENSATED
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Respiratory
Time
COMPENSATED UNCOMPENSATED
Tidal Volume
RRSpO2
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GENERAL ARREST ALGORITHM
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Oxygenation
Ventilation
Perfusion
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Confirm
EtCO2
Chest rise
Breath sounds
SpO2
Ma
xim
ize
1stA
tte
mp
t
Pre
ve
nt
Hypoxic
Arr
est
Ove
rall
Intu
ba
tio
n
Su
cce
ss
BVM1 until return
of spontaneous
respirations
SaO2>93%
Anticipate
problem
Unsuccessful7
Successful
Successful
Abandon attempt6
SaO2>93%“Can’t intubate,
can oxygenate”
SaO2<93%“Can’t intubate,
can’t oxygenate”
Partial response
to BVM
Not responding
to BVM
Successful
Unable to
intubate
Unsuccessful
Successful
1Two thumbs up” BVM, cricoid pressure, NPA/OPA, EtCO22Hypoxemia, Extremes of size, Anatomic disruption/obstruction,
Vomit/blood/fluid, Exsanguination, Neck mobility (HEAVEN)3VL or DL without paralysis, primary supraglottic/cric4Paralytics contraindicated with suspected airway obstruction5VL (TBI/trauma/anatomic/extremely large) vs. DL (fluids/speed/extremely small)6SpO2 dropping below 93%, recognition of better alternative, bradycardia7Consider repeating RSI medications
Normal
Able to
intubate
NRB
1-3”Preoxygenate
with NRB +/- NC
Assisted
ventilation
(small volume)1
Pre-
assessment2
•Consider alternative approach3
•Access adjuncts
•Access cric kit
•Cric pressure
•Sedative
•Paralytic4
SaO2>93%
BVM
(large volume)1
•1st Look5
•External laryngeal
manipulation (ELM)
1st Attempt
SaO2
<93%
ELM
VL, DL (Shoehorn)
Supraglottic
Magills
Bougie
Cric
Rapid Airway
Access
Supraglottic
Cric
Brief
attempts
Unsuccessful
Suction
Supraglottic
Cric
BVM1/temp supraglottic(Consider other intubator
or immediate transport)
ELM
VL, DL (Macler)
Bougie
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CQI Data/Analytics
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ART Data/Analytics• Institutional
• Operational
• Demographics
• Antecedent events
• Intra-arrest
• Post-arrest
• Process issues
• Clinical interpretation
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Clinical Outcomes
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Need Graph, %
0% 1% 2%
88%
81% 82%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Case 62 (pre) Case 65 (pre) Case 55 (pre) Case 74 (post) Case 72 (post) Case 71 (post)
Pre ART Post ART
CC
F (
%)
Los Angeles EMSA
ccep
tab
le C
om
pre
ssio
ns (
%)
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0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
score w/o score with feedback
Compressions in Target
Before After
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80
82
84
86
88
90
92
94
96
98
100
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
IntubationSuccess(%)
2015 2016 2017
Overall
First Attempt
First AttemptwithoutDesaturation
Air Methods Intubations
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0
5
10
15
20
25
30
35
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
ROSC(%
)
RVCFDArrestOutcomes
20182017201620152014
Riverside County FD
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0
5
10
15
20
25
30
35
40
SurvivaltoEDAdmission
Survival(%
)
ColtonFD
Pre-ART
Post-ART
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0
5
10
15
20
25
30
35
40
45
50
2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13
ArrestSurvival
Su
rviv
al-
to-D
isch
arg
e (
%)
Current U.S. Benchmark
UCSD Arrest Survival
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0
0.5
1
1.5
2
2.5
3
2006-07 2007-08 2008-09 2009-10 2010-11 2011-12
Non-ICUArrests
Arr
est
Incid
en
ce (
per
1000 a
dm
issio
ns)
UCSD Non-ICU Arrest Incidence
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1.4
1.5
1.6
1.7
1.8
1.9
2
2.1
2.2
2005-06 2006-07 2007-08 2008-09 2009-10 2010-11
OverallHospitalMortality
Ho
sp
ital
Mo
rtality
(%
of
Ad
mis
sio
ns
)
UCSD Hospital Mortality
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0
10
20
30
40
50
60
70
80
90
100
TargetRate TargetDepth CCF ROSC Survival GoodNeuro
Percent(%)
MayoFlorida
Pre-ART
Post-ART
Mayo Florida Arrest Survival
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0
5
10
15
20
25
30
35
40
45
2015 2016 2017
SurvivaltoDischarge(%
)
GeisingerMedicalCenterGeisinger Arrest Survival
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0
10
20
30
40
50
60
Sep/Oct Nov/Dec Jan/Feb Mar/Apr May/Jun Jul/Aug
Non-ICUArrests(#)
OchsnerMedicalCenter
Pre-ART
Post-ART
Ochsner Arrest Incidence
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An ART Movement
0
10
20
30
40
50
60
70
80
UCSD VA OtherUC's Mayo ED
Witnessed
CPRon
Arrival
AirMedical Santa
Barbara
ElCajon San
Bernardino
Riverside
Survival(%
)
Pre-ART
Post-ART
Inpatient ED Air Ground EMS