Post-Rosc Care

• The 2 clinicians in the rear patient cabin swap compressor/ventilation roles every 2 minutes (when the AED analyses), however, they do not swap positions. The BVM connected to the i-Gel® is moved to allow access to clinicians providing ventilations. Once a swap has occurred, the ventilator will secure themself with a seat belt. • The driver of the ambulance needs to drive to road conditions, being aware that active CPR is being performed and one officer is unrestrained. • The driver communicates with the clinicians about road surfaces, corners, railway crossings, etc. • Although mobilising to the health facility under P2 emergency driving conditions, speed may not be beneficial.

In fact, in many cases, the ambulance speed will be much slower than normal posted speed limits.

The following video shows a typical ambulance mobile CPR situation (from NSW Ambulance). Note the height of their stretcher, the uncoordinated movement of staff in the back of the ambulance, hands-off chest time, trip hazards of defibrillator cables, oxygen tubing and manual task issues. Immediately following we will show the proposed SAAS movement while under CPR (stretcher to the ambulance) and mobile to hospital. Note: this video shows SAAS paramedics using the defibrillator in manual mode, however, the principles are identical for Ambulance Officers using an AED that will prompt you to stand clear are analyses every 2 minutes.

Mobile CPR Includes a comparison between a real case from NSW Ambulance and SAAS choreography [06:04 minutes] https://player.vimeo.com/video/286835107

Return of Spontaneous Circulation (ROSC)

Ambulance Officers will recognise ROSC when the patient: • Starts breathing normally (not absent or agonal/gasping) • Shows other signs of life such as purposeful movement • Shows an increase in consciousness level (AVPU/GCS). Note that even though a patient may start breathing normally, they may remain unconscious despite a ROSC being achieved. When such above signs of ROSC have been achieved, it is reasonable to then check a carotid pulse. If there is any doubt that a ROSC has been achieved, continue CPR.

Immediate actions

• Stop chest compressions, leave the defibrillator turned on and keep defibrillation pads in place • Be prepared the patient may re-arrest again. If this occurs restart CPR and Defibrillation as per Clinical

Practice Protocol

• Request clinical support if this has not already been done. Even in remote areas request as visiting SAAS clinicians/managers may be in the area or other HCPs such as RERN Doctors may be able to respond to assist. Don’t assume you are alone. • Consider another SAAS crew of any clinical level or other emergency services i.e. SAPOL, CFS, MFS, SES to assist with extrication. • Consult with the EOC Clinician if this has not already occurred. Their advice will be invaluable. • When mobilising to a health facility early notification is required to ensure adequate staffing and in rural areas on-call medical and nursing staff can mobilise to the hospital ASAP. On the reverse side of the aide-memoire is a Post-ROSC Management checklist. Refer to the BLS sections.

Airway

Depending on the patient’s conscious state, the inserted airway e.g. OPA, NPA, SGA (i-Gel®) may remain in place. However, if the patient is showing signs of a returning gag reflex and cannot tolerate the airway, it must be removed as soon as possible. NPAs are usually tolerated well with patients, even those with altered GCS. Suctioning of fluid, vomitus or blood from the oral and nasal cavity may be required. Any gross soiling of the airway may require you to posture the patient (head turned or rolled on their side) and be manually removed by the Ambulance Officer. Vomiting post-ROSC is common.

Breathing

Avoid hypoxia in a patient where ROSC has been achieved. Once ROSC has been achieved, oxygen saturation can be monitored by pulse oximetry. Provide oxygen either via: • Bag/valve/mask resuscitation with 15lpm of oxygen (BVM may remain connected to an SGA or used with a resuscitation mask). If actively ventilating or supporting respirations with the BVM, do not hyperventilate the patient (monitor your ventilation rate and volume).