Cardiac Arrest Choreography - Pit Crew CPR

2 Rescuer BVM/CPR technique

The 2 rescuer BVM technique in cardiac arrest is greatly encouraged before an advanced airway being inserted (i-Gel® or ETT) for both adult and paediatric patients. Advantages: • Two hands to jaw lift and hold the mask on, reducing the risk of leaks • Decreases the risk of air in the stomach • With the compressor bagging over or under ventilation is addressed (both over and under ventilating can significantly reduce survival) • The compressor does not lean on the patient’s chest during ventilations addressing any risk of recoil when ventilating • The quality of CPR is improved = Increases rate of survival. NOTE: In cardiac arrest, the 2 rescuer BVM technique is used primarily as the initial ventilation technique, as a rescue strategy when i-Gel® is not achievable or in paediatric arrest where hypoxia is the likely cause and insufficient resources are on scene to allow for i-Gel® preparation and insertion without interrupting compression/ventilation. The single-rescuer BVM ventilation technique is now reserved for solo/single responder cardiac arrest management only.

When using the Bag-Valve-Mask (BVM) Resuscitator - ensure oxygen is connected, a flow rate of 15 litres per minute is set and the BVM reservoir bag inflates.

Two Rescuer BVM/CPR Technique [00:11 minutes] https://player.vimeo.com/video/293885057

What was best practice 20 years ago, 5 years ago or even 1 year ago has and will change. We need to stay “on top of the game”. • We are here to improve cardiac arrest outcomes in

South Australia. • For inspiration, to improve cardiac arrest survival we look at Seattle (USA). Seattle is often considered the benchmark for cardiac arrest survival. • Using the Utstein criteria (the international research method which examines the statistics of bystander witnessed cardiac arrest and a presenting shockable rhythm (VF or VT), Seattle achieved 62% cardiac arrest survival. We currently sit around 35%, almost half of that. Don’t get too hooked up on numbers, just know we can do better than we are now.

F1 Pit Stops Old versus New [01:16 minutes] https://player.vimeo.com/video/294701506

Why is their survival rates nearly double ours? • They have widespread public access AEDs and an extremely robust system for ensuring everyone knows CPR (starting in 1974, more than half the population have been trained in CPR). There is that saying – “don’t fall asleep on a park bench in Seattle because someone will start CPR on you!” • They have a high performing ambulance (EMS) service. What do these high performing ambulance services have in common? • Focus on HP-CPR. • Using Pit Crew Models (that forms the structure of their approach). • Robust Post ROSC (return of spontaneous circulation) management models. Salt Lake City – USA

Look kind of familiar? The population of 1.1 million, street layouts based on a grid pattern. City/Metro area, flat urban area with nearby hills and a vast countryside also. Very similar to Adelaide? They rolled out a pit crew model approach to cardiac arrest management and HP-CPR training in 2011. Then they looked at patient outcomes following this implementation and compared it to pre-implementation data and published their research.

In September 2011, Salt Lake City Fire Department EMS providers underwent a system-wide restructuring of care for OHCA patients that focused on the adoption of high-quality CPR with minimal interruptions and a pit crew model.

Am Heart Assoc. 2016 Jan 11;5(1). pii: e002892. doi: 10.1161/JAHA.115.002892 https://www.ncbi.nlm.nih.gov/pubmed/26755555

Their survival rates with neurological intact patients (no disability/brain injury on successful resuscitation) outcomes doubled from 8% to 16%!

So, what will the SAAS Pit Crew model look like?

Ambulance Officer’s focus for 2018 was on high-quality CPR, the introduction of the i-Gel® supraglottic airway and the role of the community in CPR and AED use. We did look at some basics of scene logistics and how other services were using the pit crew model. We have since refined what SAAS pit crew CPR will look like. The key points are: • Early recognition of cardiac arrest patient • 360° Access • Kit Dump • Swift i-Gel® insertion (adults) • Ventilation efficacy checked • i-Gel® checked and secured • CPR uninterrupted with advanced airway • Metronome used

• Standardised language • Use of the SAAS cardiac arrest aide memoire

Procedure - Moving an Unconscious Patient to the Floor [PRO-290]

Early recognition of cardiac arrest

Ambulance Officers routinely don’t check for a pulse during cardiac arrest. We rely on no signs of life: absence of normal breathing (remember agonal ‘gasping” breaths are not compatible with life), no purposeful movements and unconscious/unresponsive to determine a patient is in cardiac arrest.

360° Access and Kit Dump

Reflecting on the Formula 1 (F1) pit crew: • Is a controlled and well-rehearsed environment • Everyone knows their job and does it • They have 360-degree access to the race car • There is a pit crew team leader.

It is beneficial to rapidly move the patient to a clear area in which 360-degree access can be achieved before commencing CPR if possible. When we attend a vehicle crash rescue scene, we get to witness how our MFS/CFS/SES rescue colleagues set up “equipment dumps”. All rescue equipment is placed strategically on tarps. Everything has a place and everyone in the team knows where the equipment is. Regards of the vehicle crash location or type, the rescue dump is the same each time.

SAAS equipment should be placed strategically the same way regardless of the resuscitation that occurs in Rundle Mall, a workplace in Prospect, a residence in Kapunda or the Tumby Bay football oval. The SAAS standardised equipment layout “kit dump” by the first arriving crew SAAS community responders and PTS ambulance crews will place their green first response backpack where the blue airway kit is pictured, otherwise, the equipment positioning is the same.

Standardised Language

Just like a standardised kit dump, there will be standardised language and instructions used in SAAS cardiac arrest management.

Putting it all together at the BLS level

The following short video shows the SAAS Pit Crew model in action. During your face-to-face workshop, you will practice these many times. Starting in a 2 person BLS team and progressing to a 4 person BLS team. An example of a BLS HP-CPR situation. Note flexibility is required in terms of positioning based on the patient’s position, the skill level of crew members and the arrival of ALS providers who may attend. The key points are - Early identification of cardiac arrest, immediate chest compressions, early application of AED, call for clinical support, early i-Gel® insertion for adults, use of SAAS cardiac arrest aide-memoire and call to EOC Clinician.

Pit Crew CPR with BLS Providers (Ambulance Responder and Ambulance Officer) [06:36 minutes] https://player.vimeo.com/video/405713609

SAAS Cardiac Arrest Aide-Memoire and Team Leader

The initial pit crew starts with the first responder or first arriving 2-person ambulance crew, who will move in a pendulum manner switching between airway and compressions. Ideally, the pit crew model is at least 4 people, one who is the cardiac arrest leader. A crew of 4 in country SA? - Is it possible? It may not be 4 SAAS Ambulance Officers but it could be other people who can assist with quality CPR e.g. SAPOL, CFS, SES, Nurse, Surf Life Saving, St John First Responders at an event or first aid trained bystanders. You need to provide clear instructions and directions as well as feedback and coaching on their quality of CPR including rate, depth, recoil, etc. ALWAYS ask for clinical support or another resource during a resuscitation. You just never know who is passing through your area who may be able to assist. Don’t assume you are alone.