SCCM Resource Library-Feeling for a Pulse: Methods of Assessing ROSC and Hemodynamics

Video Transcription

Good morning. I'm Richard Pino, and welcome to the session of Feeling for a Pulse, Methods of Assessing Return of Spontaneous Circulation and Hemodynamics. Many of us have been to  codes where there's been confusion and difficulty assessing the status of the patient. So today  we have three presenters who will share some common sense about codes. We will have one session that would be the nuts and bolts of end tidal CO2 monitoring that we know has  been part of the ACLS protocol. Another is looking for a pulse, the use of point-of-care  ultrasound during a cardiac arrest. And finally, some common sense during codes, simple things  to remember. I hope you'll enjoy this session, and the speakers will present some outstanding information. Thank you.  Hi there. My name is Eric Kreiner. I'm the Adult Critical Care Clinical Specialist at MedStar  Washington Hospital Center in Washington, D.C. I'm going to take the next couple minutes with you to  talk about the nuts and bolts of capnography. Here's my COI and disclosure slide, as you can  see. Everything herein is my opinions and are also my slides. The objectives that we're going to  attempt to cover within the next couple minutes are first, we're going to review the physiology  of capnography and CO2 monitoring. And then I am then going to show you a couple different  capnographs, you know, from portable to more monitor-based capnographs. And then third,  we're going to specifically review the utilization of capnography during cardiac resuscitation.  So first, the physiology of capnography and CO2 monitoring. So here's the system, all the components of it that you see here on the slide. And there's several different key parts of  this. And so we're going to go through each one of them. First off, there's the pulmonary  circulation, identified in the cartoon picture there as the red blood vessel. The next portion,  you know, coming up from the bottom is the alveolus itself, followed by the conducting and artificial airway. And then finally is the CO2 detector and the monitor.  So these four pieces essentially make up the system of entitled monitoring for CO2.  Now, the physiology that is in play within those four pieces go a little bit like this. First, you have to produce CO2 at the cellular level or the metabolic component of this. So  CO2 is produced. It then needs to circulate and be perfused through the lung or the pulmonary  circulation. So that's the next portion of this system. And then you have to ventilate. And so  at that point, CO2 that was produced at the cellular level circulated to the lung is then  exhaled out. And we'll go through the monitor, which you see there at the top of the airway,  and that being the fourth part of the system. And so basically that is, you know, the nuts and  bolts of the physiology of how we monitor an exhaled CO2. That exhaled CO2 being monitored  produces, you know, preferentially what's called a capnograph or the graphical representation of  CO2 within the exhaled air. You see a series of breaths here of a capnograph, time being across  the horizontal axis and the actual amount of CO2 being on the vertical axis. There's also a few  key components. I'm going to take one of those breaths out of that cycle, and we're going to  look at those components of the capnograph, this being the entire capnograph that you see here.  But as you break it down into its individual components, the first part of it, the CO2 is  lying along the baseline or zero here. And that is because as the air empties, that which you can see  on the right hand or left hand side of the screen, air is emptying from the conducting and or  artificial airway and has not participated in gas exchange. So therefore the CO2 that is  in this portion of the gas is zero. And so the first part of exhalation is actually  zero represented there on the capnograph. As the lower conducting airways begin to empty,  some of that gas is mixed from alveolar gas. And what you see is a rise in the CO2 concentration.  And that's the upslope on the left hand side of that capnograph that you see being produced.  And then finally, as the alveolar gas empties, that is laden with CO2 from gas exchange at the  alveolar capillary membrane, begins to empty. The CO2 concentration within that exhaled gas  goes to its peak. And that is where you see the plateaus start to form, forming the top part of  your square capnograph. The highest value of CO2 that is exhaled, that at the end of the breath,  or the end tidal, that denoted by the blue arrow there, that is what the quantitative measure of  end tidal CO2 is, or what is being displayed to you. Not necessarily any of the CO2 levels prior  to the end of this waveform, but essentially just the end tidal CO2. All right. The patient then  inspires on the next breath, denoted by the green arrow going into the lung. And hopefully that  inspired gas contains zero CO2. There's no rebreathing of exhaled gas. It's fresh gas going  in. And so therefore the concentration of CO2 within this gas is zero. And what it produces  on the capnograph is a downslope back towards the baseline or zero level. And what you have formed is a nearly square end tidal capnograph. And so this would be considered normal,  each portion of it being reflective of a portion of the lung that's emptying here. So the types of  monitors that you can use to detect this, there are a couple different ones on the market,  and I think it's important to understand which ones you're using and, you know, some of the  different types. The first one is really what is called a colorimeter. This is, you know, I think  in clinical terms you might hear it called a capostat or something like that. But what you  have here is a chemical reaction on paper that changes the color of the paper from purple to  yellow depending on how much CO2 is in that gas. And so what you are left with is kind of a  rudimentary do you have CO2 versus do you not have CO2 with that color change. It's really kind of  subjective here. As you can see along the outside of that rectangular adapter there, there are different levels of CO2 for the quality of that color change that tend to match up  with the amount of CO2, but again that's kind of a subjective measure. Nor does this colorimeter  produce any type of graphical representation for you. So what it is is a really quick, easy, inexpensive way to understand whether you have CO2. But you lose a lot of the  granular detail within that analysis. The second thing or second way that you could use this  is really the portable end-tidal CO2 and capnography. Both of which you see here, two just  different representations. There's many, many different ones on the market. The one on the right,  you know, being one that's connected to an adapter that goes right in line to the airway so it's a  mainstream capnograph. The one on the left being a side stream in which there's a sampling line for  gas. That's why I picked these two different kinds of examples. But the key thing is that they not  only give you a quantitative measure of how much CO2 is in the gas, but they give you a graphical  representation as well, which we had just previously gone over. And then there's the same idea, but taken out of the portability space and put actually onto a patient monitor,  which you see here. So a couple different ways that you can monitor end-tidal gas.  Now the utilization of the capnography is a big can of worms to open up. We clearly don't have the  time to do that, nor is it within the scope of this particular presentation. But I will represent  all of them here for you before we get into a little bit of detail. We can usually use capnography  in the monitoring of cardiac and pulmonary physiology in intubated patients and non-intubated patients, but primarily patients that are invasively ventilated. We use it for  peat titration and understanding of other pulmonary physiology. There's the idea that utilizing capnography for tracheal intubation confirmation, as well as during cardiac arrest  and resuscitation. And finally, the other space in which capnography is used is during procedural  sedation or analgesia. So the idea that capnography exists across the spectrum of patient care is  there. This particular talk, we're going to focus on these two, the tracheal intubation confirmation and cardiac arrest. So within tracheal intubation, essentially we're trying  to understand is the airway within the trachea or is this an esophageal intubation? And then  within cardiac arrest, we can understand the quality or the effectiveness of chest compressions, whether ROSC or the return of spontaneous circulation has occurred, and thirdly,  the determination of futility of the resuscitation effort. So in some detail,  end-tidal capnography is a really, really good way to understand whether your airway is in the trachea or not. That with direct visualization of the airway passing through  the vocal cords is the well-accepted standard of care, really, in clinical practice. It has a very, very high true positive and negative rate for confirming endotracheal intubation.  I will say that there are some caveats that prior to the introduction of the tracheal airway, whether a bag valve mask delivery of gas was being done for the patient,  whether there was any gastric insufflation or carbonated liquids, if the tube makes it into the esophagus as opposed to the trachea, there could be this false positive reading of  CO2 that isn't necessarily reflective of the tube being in the trachea. So something to just kind  of keep in mind there. The other space that we're going to kind of hit the highlights on is the use  of end-tidal CO2 in capnography during cardiac arrest and resuscitation. And again, there were  three main areas that we were going to kind of highlight here. First is the effectiveness  of chest compressions. According to VHA and other published literature, achieving a PETCO2 of at  least 10, preferably 20, is a marker of really good chest compressions. And that is because  without the effective chest compressions, you don't have the perfusion component of that system  that we talked about a couple of minutes ago. And so you don't have the circulation of CO2  into the pulmonary circuit, and therefore it is not available to be exhaled. And so what you can  see here is this linear representation of end-tidal CO2. And there on the left, prior to this big dip  here, is that the patient is not having effective circulation, and you can see a decrease in the  end-tidal CO2. There's a rescuer change here, and now the input essentially of a rescuer that does  have effective chest compressions. And so you can see the rise in CO2 representing the increase in perfusion with those effective chest compressions. So a good way to understand  whether you're doing a good job of CPR. The other idea is that the end-tidal  capnograph can tell you about the return of spontaneous circulation, and that again is based  on the premise that the restoration of perfusion is now there, right? And so if you have pulsatility  and perfusion, then CO2 makes it to the pulmonary circuit and is now available for exhalation and  now shows up on your capnograph. And what you'll see is a sudden sharp rise in the monitored end-tidal CO2, and it's a great marker for the return for RASC. Though there is some,  you know, debate whether you see RASC, whether compression should be stopped at that point,  that isn't where the guidelines are going. Really this is a marker of it, and at the next pulse  check what you would expect to find is the presence of that pulse. And so that's what this  is telling you here. The third thing is the prediction of your outcome in your resuscitative  effort. So the end-tidal CO2 should be high. The mean levels that are higher correlate with RASC,  though you absolutely have to note that end-tidal alone should not be used for this prediction of  outcome. So in general, in much of the literature, a low end-tidal CO2 for a long period of time is  associated with futility in the outcome because of a lack of coronary and cerebral perfusion.  A low end-tidal for greater than five minutes but less than 20 is associated with poor outcomes  neurologically afterwards. And so these are good ideas to have, though again, you don't essentially put all your eggs in the end-tidal basket when making that determination for  futility and prediction of outcomes. And then, you know, in the last remaining seconds,  we also have to understand the confounders of end-tidal during resuscitation. And so if you  think about it, the administration of adrenaline or epinephrine will increase the coronary and  cerebral perfusion. And we, you know, we all understand that and hence why we give it. But  what also happens is a pulmonary vasoconstriction, which decreases perfusion, therefore would decrease end-tidal CO2. The administration of bicarb, because it dissociates across the  hydrolysis equation, would transiently increase your CO2. And so things that you have to think  about as you are attempting resuscitation and how they affect your end-tidal or exhaled CO2. In summary, what we talked about was the physiology of the capnograph and CO2 being  exhaled is reliant on its production, its circulation to the lung, and the ability to ventilate, the different types of monitors that are out there, and its usefulness within the  resuscitative effort. Again, my name is Eric Kreiner and we discussed the nuts and bolts of  capnography. Well, thank you very much for giving me the opportunity to present looking for the  pulse to use the point-of-care ultrasound for cardiac arrest. I'm a cardiac anesthesiologist and intensivist at the Massachusetts General Hospital. I have no disclosures.  I'm going to be talking about checking for a pulse, how good really is it, the pros and cons  of ultrasound for pulse checks, and then how to do it. So how good are we at it? On the left,  you see the ACLS algorithm, and every two minutes you check for a pulse, you check for a rhythm,  and it turns out we are absolutely horrible at checking for a pulse, as seen in the study by  Everly et al., where they took first responders into the cardiac ORs to check pulses on patients  who are on and off bypass, and only 15% of them produced correct diagnoses within 10 seconds.  2% identified pulselessness correctly within 10 seconds, and the median diagnostic delay was 24  seconds. In fact, it was much higher at 30 seconds when no pulse was found. So clearly,  assessing pausatility by palpation, physical exam, is not good.  What are other ways to assess pausatility? Certainly arterial lines are ideal  in assessing pausatility. However, in cardiac arrest, they may not be ideal to place. And then  end-tidal CO2, which was talked about in an earlier session, as well as pulse symmetry, if there's a good waveform, would suggest pausatility.  How about ultrasound? So ultrasound technology has certainly improved over the last couple  years, or the last decade plus, to become much more portable and affordable, and many of these  probes fit in your back pocket, and they can be deployed really quickly into chaotic situations,  such as this, where a patient's undergoing cardiac arrest, and the quarters are very, very tight.  The image quality is comparable. So you have the G-Vivid E95 here, which is 80,000 plus dollar machine, compared to the Philips Lumify, which is about 10,000 dollars,  depending on the probes that you get, and the quality is comparable.  Here you have the V-Scan, which is about a 5,000 dollar device, the Butterfly Q, which is about 2,000 dollars, and the image quality is pretty good for making a binary decision.  Transesophageal echo is increasingly being used at many centers, mainly because you don't need to  stop chest compressions in order to evaluate the heart. The image quality is  far superior, because this probe goes down through the esophagus, it sits right behind the heart,  and the learning curve is typically lower compared to TTE. The downsides, you know, certainly is that these machines can be bulky, they can be incredibly expensive,  these probes are very pricey, and also there is a risk for esophageal perforation,  especially in patients with esophageal issues. So what are the pros of ultrasound for pulse checks?  So in the ACLS algorithm, you want to identify reversible causes, and when ultrasound is used as an extension of your physical exam, you can quickly rule in and rule out  things such as tension pneumothorax, PE, pericardial effusion, assessed hypovolemia,  and in the study by Gaspari et al., they found that ultrasound identified findings that responded  to non-ACLS interventions such as pericardiosynthesis, chest tube placement, thrombolytics,  et cetera, and patients with pericardial effusions and pericardiosynthesis had higher survival rates  at about 15.4% compared to all others, 1.3% survival. So about a 12 times increase in survival  rates when you can identify the reversible cause. In their study, they also found that 54% of  patients with PEA had cardiac activity on initial ultrasound, and cardiac activity was associated  with increased survival at the hospital admission and hospital discharge. In this systematic review  and meta-analysis by Salet et al., they found that spontaneous cardiac movement predicted ROSC,  so with about 95% sensitivity and 80% specificity, the positive likelihood ratio was 4.8%,  the negative likelihood ratio was about 0.06%. So ultrasound can identify true cardiac stance,  so this is during chest compressions and then following chest compressions during the pulse  check, you see cardiac stance still, which is essentially asystole, whereas this is pseudo  PEA arrest, where you see organized cardiac activity. And so ultrasound in these settings  could identify whether or not there's cardiac stance still, which may be more amenable to low-dose  pressers. Actually, with pseudo PEA arrest, it's probably more amenable to low-dose pressers,  and perhaps CPR is not ideal in cardiac stance, so you definitely want to do chest compressions.  Ultrasound can help identify pericardial effusion, RV strain suggesting PE, and then arrhythmias,  so it can identify asystole, which is true PEA arrest versus  fine V-fib and organized activity. It's helpful for ruling out pneumothorax. You see lung sliding and then assessing for volume status.  And so the International Federation for Emergency Medicine, they put out a consensus  statement on the use of point-of-care ultrasound during cardiac arrests. They brought together 24  recognized international leaders and POCAs from emergency medicine and critical care medicine,  and these consensus protocols for cardiac arrest was reached after three rounds of the modified  Delphi process. The protocols received greater than 82 percent approval of panel members. On the left, you see the shock protocol for cardiac arrest, and the core views are the  subxiphoid and the parasternal cardiac view, certainly subxiphoid is probably more ideal, given the fact that  it's not in the way of chest compressions, and they recommend performing it during pulse checks,  looking for pericardial effusion, RV strain, and then function, so identifying asystole versus  organized cardiac activity, or fine V-Fib. And then supplementary views include of the lungs  and IVC, looking for pneumothorax and IVC and filling, and then additional views looking at  endotracheal tube conformation, where enteto-CO2 may not be reliable, also looking for DVT and  then free fluid in the abdomen. Next, I'll talk about the cons of ultrasound for pulse checks,  and that being it delays chest compressions. And so this has been seen in a number of studies, including by Huiz et al., where in their prospective cohort study of 23 patients,  they found that the mean duration of pulse checks was increased by about eight seconds with POCUS. And this was also seen in the Klattenberg prospective cohort study,  where they evaluated 110 CPR pauses, and they found that POCUS caused the median CPR pause to increase by about six seconds or so. So the take-home message from these studies is  not to stop doing ultrasound, but we have to figure out how to do ultrasound quicker.  And similarly, you wouldn't stop using antibiotics just because they can cause drug resistance  and C. diff, and you wouldn't stop washing your hands just because it can damage your skin  and cause germs to grow and thrive. I think we need to figure out how to provide the education and how to have providers do these ultrasound pulse checks quicker.  And as I had mentioned earlier, when ultrasound is used as an extension of your physical exam,  you can identify reversible causes much quicker. So in this study by Yaman et al., they found that  when with education, they were able to bring down the pulse check duration. So without POCUS,  they were able to decrease pulse check duration from 17 seconds to about 10.5 seconds. And then  with POCUS, they were able to reduce the pulse check duration from about 20 seconds to just  under 10 seconds, so 9.9 seconds. So education matters. Does experience matter? Absolutely.  So in this study, the same study by Klattenberg et al., they found that when an ultrasound fellowship trained faculty performed the ultrasound, CPR pauses were shorter by about 4.1  seconds. And then the next question is who should be doing it? Should it be the team leader or should there be a designated person doing it? So when the leader also performed POCUS,  the pulse check durations were prolonged by about 6.1 seconds.  In this comparative study by Zangen et al., looking at comparison of manual pulse palpation,  cardiac ultrasound, and Doppler ultrasonography, where the ultrasonographers were very experienced  and had been using cardiac ultrasound and resuscitation practices for a year, they found  that cardiac ultrasound for pulse checks was much quicker compared to Doppler ultrasound or  manual palpation of the femoral artery. So when an experienced provider is performing cardiac ultrasound, it's almost cut by half the duration. And here you see that when the  false positive and false negative rates are much higher with manual palpation compared to Doppler  ultrasound, when cardiac ultrasound is used as the gold standard. So experience matters.  And so when you're performing cardiac ultrasound, this is a skill that has a significant learning  curve for anybody who's tried to teach anybody ultrasound. Whereas, say you're checking the  pulse by looking at the carotid artery as we do whenever we put in a central line, you're looking  to identify the vessel that's not pulsating and that is compressible. So in this case, you want to identify the vessel that's pulsating and not compressible, the carotid artery.  And in this study by Bajra et al., when they compared POCUS carotid pulse checks versus palpation, the duration times were essentially very—there was no significant difference.  As far as first attempts at detection of pulse checks, they were much more successful in the ultrasound group compared to the palpation group. So lastly, I'll summarize how best  to use ultrasound for pulse checks. So education is key. You want to minimize time off the chest.  CPR is the most important thing during cardiac arrest. And you want to have someone counting  down from 10. It should be a designated person, not the person performing ultrasound. And once  you've finished counting down from 10, CPR should start immediately.  Ultrasound should be performed by the most experienced operator. Ideally, it's the person who has ultrasound fellowship experience, not necessarily the most experienced  clinician. It may be the intern who's a POCUS enthusiast and who has done many, many POCUS—or  it may even be the UC Irvine student. Their whole class ended up getting these portable ultrasound  devices, and they've done many, many ultrasound studies. So whoever's most experienced  with ultrasound should be the one doing the study, and it should be a designated  person. So this is the HA positions for a six-person high-performance team. I argue it should be seven, but it should be a designated person doing ultrasound, not the team leader.  You want to save your images so that you can review them during CPR. During the pulse check,  things are very, very chaotic, and oftentimes it's hard to assess what's going on. So if you  record the images, you can review them during CPR, and they're also helpful for QA processes as well.  The other thing is you want to answer a single question at the time. So this is the CASA  protocol, and the study by Gardner et al, they found that if you answer a single question,  whether or not there is an infusion the second time around when they're using POCUS, if there's  RV strain the third time around, if there's cardiac activity, if you just focus on one question at a time, you can shave off about four seconds from your pulse check  duration. So the other thing is you want to be in the ready position. So in that same study  by Gardner et al, they found that, you know, if you have the ultrasound on the patient's chest  before stopping CPR, you can shave off an additional 3.1 seconds. And so hopefully I was able to convince you all to do ultrasound during cardiac arrest and how best to do it.  Thank you so much for your attention. Hello, I'm Kaitlin Tin-Lohaus. I'm a critical care  nurse practitioner at Emory St. Joseph's Hospital in Atlanta. Thank you to the society for allowing this virtual Congress to happen. I will be presenting common sense during codes,  simple things to remember. I have nothing to disclose. So before we begin our discussion,  I just wanted to ask, what do you think is a good code? Think back to a code blue that left  you feeling proud to be a part regardless of the outcome. What made it good? Was it good CPR,  good crowd control, good teamwork, early shocks? What in your mind is a pinnacle of a good code?  The next question I want to ask is, do you feel confident leading a code? I imagine yes, because as resuscitationists in the ICU, this is our job. But I do want to make you aware  of a study that was recently published about clinicians' perspectives leading code blues.  In this study, they asked clinicians, attendings, nurses, residents, if they felt confident leading  code blues, if they worried about making errors in code blues, and if they felt confident in participating in code blues, or if they had difficulty thinking clearly in code blues.  It was interesting that everyone felt confident participating in code blues, but only 50% of  residents and 25% of nurses felt confident leading code blues. And everyone, most people, attendings, nurses, and residents, felt worried that they would make errors in code blues  situations. So this is just something to remember and something I think we can grow from, no matter  if you're attending or a nurse or resident or an APP, just making sure your whole team feels confident in code blues. So how are we doing as a nation for code blue survivals?  From 2000 to 2018, the last time we really saw a change in survival was after the 2005 publication of the AHA guideline revision that focused on CPR and AEDs. This showed today,  unfortunately, one in four patients survive in hospital cardiac arrest. It hasn't been since  those 2005 guidelines that our survivability trend has increased. This is something that we really need to look into about doing more research in this specific population.  So code blue survival in 2000 to 2016 by rhythm. This is also another study that was very  interesting that shows that VTAC and VFIB rhythm arrest actually have a more chance of survival  than ASIS, SLE, and PEA arrest. And that's going to become more important when we talk about the  errors that are common in code blues. Furthermore, when comparing survival to discharge rate by  rhythm, VTAC VFIB arrest survival to discharge rate remains higher than non-VTAC VFIB arrest. This is important as we explore common errors in code blues.  So early initiation of high quality CPR and early shock remain the interventions associated with  best clinical outcomes. This is the gold standards. We know that. But are we doing that? I arrived to  a code the other day, and they were doing compressions, getting an ADG, and working on  an airway, but the pads were not a patient. And I know that it doesn't only happen at my hospital.  Dr. Novak, an ED physician and combat pilot, compares combat aviation to emergency and critical  care medicine. He makes the point that our critical care world can be chaotic emergencies,  but they can be protocols, protocolized similar to combat aviation. A combat aviation concept  is that that is talked about on day one of aviation training is the boldface. The boldface are responses to problems that have to have action now, or people will die. After you  accomplish your boldface, you go to your other checklists and resources and solve the problem.  The boldface solutions are memorized, second nature. So when you're incredibly overwhelmed, tasks saturated, and time is short, you can function and survive. So this is our boldface  here. Early initiation of high quality CPR and early defibrillation of shockable rhythms.  How many times do you write to a code and one of these things are not happening?  So I wanted to look at a study that was done in 2011 that actually showed common errors associated  with decreased survival. In this study, they took 200,000 in-hospital cardiac arrests and saw that  70% had no errors, but 30% had one or more documented system errors. More errors were  made in V-fib and V-tach arrests, interestingly, and the most common errors were 43% medication, 19% defibrillation, and 17% airway and 7% chest compressions. Furthermore,  they looked into which of these code blue errors were associated with decreased survival.  The study further looked into the hazard ratios of death prior to hospital discharge of these errors.  For non-V-fib V-tach arrests, chest compressions, vascular access, medications, protocol deviations  were found to significantly increase hazard ratio for death prior to hospital discharge. And for V-fib and V-tach arrests, vascular access, medications, protocol deviations,  and defibrillation errors increased the risk of death prior to discharge. So, now that we know the most common errors, let's break them down, and with simple ideas,  let's see how we can do better by our patients.  The common errors that were seen with medication during code blues were the delay in epi administration  of greater than five minutes from code blue initiation, wrong route of administration, wrong dose, and wrong medication selection.  Other ways to improve medication errors can include using smartphone apps, such as code  blue mobile applications to help you get through the protocol, and also retraining outside of the  ACLS education. Other drugs have been shown to help. I just want to mention that, unfortunately,  the data really just shows short-term effects of epinephrine and achieving, and epinephrine does  help achieve ROSK more, but really long-term effects haven't been seen in any of our code blue drugs. But hopefully more research will provide some light into that.  Certain, three randomized control trials have shown that epinephrine, vasopressin, and solumedrol  can help with neurological outcomes, but the AHA has not yet published that. They have just said  that it's a great combination to consider during a code.  Imiodarone may also improve short-term survival, but has no long-term mortality benefits. Sodium bicarb has not been tested associated  with improvements in the rate of ROSK or survival to discharge.  So, another common error that was seen was vascular access. The delay of vasoconstrictor  administration greater than five minutes from code blue initiation was seen. Inadvertent arterial  cannulation when attempting a central line was also seen, and infiltration or inadvertent  disconnection of an IV line was also seen. I've actually seen all of these this year,  I've actually seen all of these this year. So, it's something we can definitely improve on.  Ways to improve include training in addition of the IO to our code blue cart. Hopefully,  this is already done at your institution, but just making sure everybody knows how to use these.  And if you are good at, if you already have master's ease, I just want to remind you that the proximal humerus site is a preferred site and actually has six times the flow rate as a  proximal tibial site. Now, the proximal tibial site sometimes can be easier to get to,  but the flow rate is not as good. For defibrillation,  the common errors that have been associated with that have been delay in initial defibrillation greater than two minutes from code blue initiation, insufficient trained personnel,  defibrillation not available, energy level too high, and shock given not indicated, shock indicated not given, and defibrillator malfunction.  So, this is something we can really improve, whether that's by our code blue  smartphone apps, retraining outside of ACLS education, and interactive defibrillators. One thing nice about the interactive defibrillation is you can see the filtered  rhythm under the CPR rhythm that can allow you to give a shock when needed without having to  do a rhythm check. Common errors that we also see is just deviation from the ACLS guidelines.  This is something I think having the protocol at the bedside would really help. ABH, back to our aviation fighter pilots, they have protocols after their boldface that they  use in the air. This just allows you to have more mental space and mental capacity to make sure that  you're at least doing the protocol, and then after that, you can have more mental space to  go through your diagnostics. Also, back to the smartphone apps, MetaCode is a really great app  that you could use. It's something that our residents use all the time that takes you through the algorithm and even gives you a step-by-step and asks you questions about what's  happening in the code scenario, and that could really help focus your team in order to make  sure that you're going through and not deviating from the protocol. So chest compressions, we all  know that quality chest compression, that's part of our boldface to make sure that we have quality  chest compressions, but we still see that rate is not maintained. There's a delay in starting chest  compressions, interruption of chest compression, and there's a board missing under the patient for  chest compressions. Ways to improve this, eliminate those pulse checks with some more A-lines after  you've started your CPR and at least you've done your shock. Eliminate rhythm checks with  the filtered analysis like we just talked about from your interactive defibrillator. Mechanical  CPR has not been shown to be better than quality human CPR, but it can get people out of the room  during the code. So that can make your room more calm. Also, these interactive defibrillators can tell you if you're doing the appropriate depth rate and recoil, and I think  that's really great too to make sure you're giving quality chest compressions. Airway, common errors  that we see are giving more than one breath every six seconds, and then we see aspirations secondary  to multiple airway attempts, airway intubation attempts. Ways to improve that, my colleagues just  talked about end tidal CO2 monitoring. I think we're doing our patients a disservice if we don't  have that hooked up, but also we should always be using our glide scopes or Buji for ET tube  placement, and then there's another idea out there. Use your ventilator for breath, not your hand. When  your heart rate goes up, you have no concept of time, and this is a stressful situation.  So the idea is just make sure that you put your peak pressures high to a higher setting so that you get breaths when you're doing compressions, but use your ventilator for  breaths and not your hand. So communication, your communication during a code should be  directive, descriptive, and informative. So, you know, Caitlyn, get an IO where the descriptive  would be left humorous, informative, because we need access. A pre-brief, I think, is always good.  If you have time, give information about the patient, identify the leader, and this will identify who the leader is and give roles. So furthermore, resuscitate by voice. Thinking  out loud always helps the team. It helps tell the team where you are in your algorithm, and also with your differential, a summary of what's happening. A tactical pause is great.  10 seconds for 10 minutes. That's in the anesthesia literature. Just talking about giving yourself and the team 10 seconds to talk about the plan can actually make you  more efficient for the next 10 minutes. Ask the team, what am I missing, and also just realign  the team. Take a step back. Closing the loop, we all know when you call out and you tell someone,  hey, Caitlyn, put in an IO. Check back. That's when the person who has the task says, okay,  I will put in an IO, and then that confirms, or you can correct the task. But what I really like  in this closing the loop is setting a notification. All right, so also tell me when you have completed  that task. That frees up some mental space, so I don't have to think about that anymore, but then when you tell me that that task is complete, then I can say, okay, the IO is in,  then you can give the epinephrine or whatever you need to give.  So the next thing is debrief. I thought this study was very interesting. This looked into  45,000 code blues, and it showed that only one in seven hospitals frequently debrief after code  blues, and the debrief rates were 45% rarely, 43% occasionally, and 14% frequently. Interestingly  enough, debriefing frequency was not associated with better adherence to our ACLS best practice  or higher rates of code blues, but by no means do I think that this means we shouldn't be doing  debriefs. I think debriefs are where the learning happens, and they're very important. If anything,  this study just shows us that we need to be doing them more, because one in seven hospitals  debriefing is not good. So back to our aviation colleagues. They will debrief two to five hours  for one one-hour event. So this is where the learning happens. This is where it's important. Ways to improve in our debrief. We want to debrief as a group after the code. Obviously,  we don't have time to sit down for five hours after a one-hour code, but two minutes. It needs to be nonjudgmental. You want to talk about everything chronologically that happened.  You want to discuss good and bad aspects of the resuscitation. You want to reinforce learning points, and you also, this is not a time to give negative feedback. The beneficial  outcomes of this debrief will be that you will be able to learn from your mistakes, but also it  releases tension from the team, and it builds team unity. Thank you so much. I hope you learned something from that. If you have any questions, feel free to reach out.

Video Summary

In this video, the presenters discuss methods of assessing return of spontaneous circulation (ROSC) and hemodynamics during cardiac arrest. The first presenter talks about the use of capnography, which measures the levels of carbon dioxide in exhaled air. Capnography provides information about the effectiveness of chest compressions, the return of spontaneous circulation, and the prediction of outcomes during resuscitation efforts. The second presenter discusses the use of point-of-care ultrasound during cardiac arrest. Ultrasound can be used to confirm tracheal intubation, assess for reversible causes of cardiac arrest, and monitor cardiac activity during chest compressions. The third presenter focuses on common errors and best practices during codes. The presenters emphasize the importance of early initiation of high-quality CPR and early defibrillation for improved outcomes. They also discuss common errors in medication administration, vascular access, defibrillation, and adherence to ACLS guidelines. They provide recommendations for improving communication, such as using clear and directive language and incorporating debriefings after codes. The presenters highlight the importance of continuous learning and improvement in resuscitation efforts.

Asset Subtitle

Resuscitation, Procedures, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Discuss the physiology of end-tidal CO2 monitoring
Apply the concepts of point-of-care ultrasound during resuscitation
Consider common errors during resuscitation

The Nuts and Bolts of End-Tidal CO2 Monitoring
Eric Kriner

Looking for the Pulse? The Use of Point-of-Care Ultrasound for Cardiac Arrest
Marvin Chang

Common Sense During Codes: Simple Things to Remember
Caitlin ten Lohuis

Meta Tag

Content Type Presentation

Knowledge Area Resuscitation

Knowledge Area Procedures

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Monitoring

Tag Point of Care

Tag Oxygenation

Tag Cardiothoracic Critical Care

Year 2021

Keywords

ROSC

hemodynamics

capnography

ultrasound

chest compressions

resuscitation efforts

communication

continuous learning

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.