Peter Antevy walks through updated cardiac arrest protocols: one breath every 10 seconds for all patients, head-up positioning after intubation, and double sequential defibrillation starting on shock four. Each minute without defibrillation increases death rate about 10 percent. Hyperventilation above 14 breaths per minute correlates with very poor survival.
Questions this video answers
One breath every 10 seconds (10 "Mississippis").
Approximately 15 to 30 degrees.
If VF/pulseless VT persists after three single shocks, deliver double sequential defibrillation on shock #4.
When at least two defibrillation shocks are required (≥2 shocks).
About a 10% increase in death rate for each one-minute delay.
Chapters
Today we're going to talk about the new protocols and specifically how it relates to our cardiac arrest protocol. One of the most obvious changes you'll see is elimination of the distinction between primary and secondary cardiac arrest. We're going to be breathing for all patients right from the get go. And you'll also see that we've made uniform both the adult and the pediatric cardiac arrest, especially when it comes to the ventilatory rate at one breath every 10 Mississippis or 10 seconds. So let me explain the physiology behind this. We do know that when somebody goes down, especially an adult goes down, 90% of the time they have a cardiac arrest because of pump failure and they go down, they've got significant oxygen stores. That was the thinking behind the old way we did cardiac arrest where we could delay breathing for those patients. However, we've learned some more about the physiology of cardiac arrest and the expansion of the lungs, which occurs from us giving those breaths, is really critical to allowing forward blood flow. As the lungs collapse, it also collapses the arteries in the lungs and that creates tremendous resistance to forward blood flow during cardiac arrest. So those first two big breaths we give during cardiac arrest is really important to expand the lungs, but also to expand the arteries to allow the blood to flow through. And then breathing once every 10 seconds or once every 10 Mississippi's will help keep those lungs expanded as well as provide oxygen so that those arteries are open to allow the blood to continue to flow. You'll see that there's an additional breath that we're asking you to give again, a nice big breath. Just like the first two initial big breaths that occurs at every rhythm. Check again. This is not so much an oxygen thing as it is an expansion of the lungs to allow those arteries to expand to allow good forward blood flow without much resistance. A few fine points on our cardiac arrest protocol. Much of it is the same, but. But when you look at a couple of different things, I just want to highlight them first. Once you have an airway in there, a supraglottic airway, we know that it's very important to tilt the head up a little bit to allow the venous blood to drain out of the brain, that makes a little bit more room for the arterial blood to get up there. And we know from head up CPR that that's a valuable thing to do. But also on the post resuscitation standpoint, I want to make sure that we know that the patient is tilted up a little bit, somewhere between 15 to 30 degrees again to allow that good blood flow into the brain and not to have the brain engorged with venous blood while lying supine. So when we first started double sequential defibrillation, we were doing it after the fourth or fifth shock. But now the new science has come out from Dr. Chesky's in Canada that shows that the survival rate is best if you only do three regular defibrillation shocks. And if you don't get the patient back after the third shock, shock number four should be a double sequential defibrillation shock. Otherwise you're really delaying too long. And we see this in lots of areas of medicine that if you delay the effective therapy too long, it loses its effectiveness. So shock number four is a double sequential defibrillation. Also, if you're going to the double sequential, that means you've met indication for esmolol. Let's discuss a couple terms that cause some confusion. Refractory V fib and recurrent V fib. And it's important because it goes a little bit into our indications for amiodarone. So refractory V fib means it doesn't matter what you do, you can't get them out of it. It means you shock them, you shock them, you shock them. Those are typical double sequential defibrillation cases. You've shocked them three times in a row. They didn't even temporarily come out of the V fib or the pulseless V tach. That's refractory. And then there's recurrent, where you've shocked them and everything's great. They've come out of the V fib or the pulsus V tach, but then they go back into it. That's recurrent. So anytime the indication for amiodarone is at least two shocks. So anytime somebody needs at least two shocks, that shows that they're either refractory or have recurrent, both of which are indications to start amiodrone to kind of hold them in that good rhythm. Let's talk about best practices in CPR and one of the most critical things that you can do to save a life. Number one, hands on the chest as fast as you can do it. Keep in mind the pump's not moving, which means you have to be the pump. And once you start, eliminate the pauses in cpr. Every time you pause the hands on the chest, you've essentially, since you're the pump, you've put your patient into asystole. Now let's talk about shocking. For every one minute you delay shocking for a shockable rhythm, the death rate is 10%. Right now we're seeing two and a half to five minute delays in getting defibrillation done. Once we get on scene, we need to shorten that up. We want to get it ideally as short as possible. That is absolutely life saving for shockable rhythms. And shockable rhythms already is, is the group that we have the most likelihood of saving. So we want to really prioritize that. That should happen before the Lucas device. It should happen really as soon as you are in position to deliver that shock. Deliver that first shock right away. And then let's talk about the breathing. Now, obviously we're going to breathe for everybody, but let's not give up our good discipline in terms of we cannot hyperventilate for patients. We have to get a little oxygen in, we have to expand the lungs because of the forward blood flow issue that I explained. But if you breathe more than 14 times per minute for an adult, survival rate is essentially zero in some of these studies. Let's make sure we're not hyperventilating. Patients either count Mississippi's or use a metronome. One breath every 10 seconds and that's it. Let's talk about the use of ultrasound for pulseless electrical activity. Pea can really be divided into two things. And first of all, the definition of pea is an organized rhythm greater than 20 beats per minute. Anything less than 20 beats per minute, treat as asystole. If you've got greater than 20 beats per minute and you do an ultrasound and you see that the heart is actually contracting, that is not really pulseless electrical activity, that is severe hypotension and should treat it as such. If instead.
You have a rhythm that appears to be PEA and you put the ultrasound on and you don't see the heart moving, really now you're talking about somebody that has true pea, likely very poor outcome. And you should go through your usual cardiac arrest resuscitation trial. But unless something turns around, that patient will probably not have return spontaneous circulation. Pea with cardiac motion, however, is more than 50 times more likely. To get Ross grade, you have to understand that heart is beating, probably needs some fluid, probably need some epinephrine. Don't give up on those. Those are very, very good chance that you're going to get those people back. Sam.
