Perspectives on current resuscitation guidelines, techniques
EMS medical directors discuss pediatric and pregnant patient resuscitation, the use of active compression devices and head-elevated CPR at Gathering of Eagles
DALLAS — Resuscitation guidelines for pediatric patients and pregnant women in cardiac arrest, as well as the efficacy of innovative techniques used during resuscitation, were discussed by five medical directors at the 2016 Gathering of Eagles XVIII EMS State of the Science program.
In the first presentation, Peter Antevy, MD, representing the Greater Broward County (Fla.) EMS medical directors association, answered three questions — should fluid be given to children in shock, should atropine be given before intubation, targeted temperature management after ROSC — in his presentation about pediatric resuscitation.
Kathleen Schrank, MD, medical director for the city of Miami, discussed the management of cardiac arrest in pregnant patients. The AHA for the first time addressed cardiac arrest in pregnancy with in-hospital and EMS recommendations.
Jeffrey Goodloe, MD, NRP, medical director for the City of Tulsa and Oklahoma City, and Joe Holley, MD, medical director for the City of Memphis (Tenn.), discussed the efficacy of active compression devices for CPR and use of an impendence threshold device. The co-presenters discussed how the devices improve venous return during compressions which enhances cerebral blood flow.
The emerging role of intrathoracic pressure regulation or modulation during resuscitation was the subject of a presentation by R.J. Frascone, medical director for St. Paul, Minn. He described the thoracic pump theory for compression and decompression and how that physiology affects blood flow.
The final presenter, Paul Pepe, MD, closed the session with a discussion of head-elevated CPR, which is also known as gravity assisted CPR. Pepe described the flaws of supine chest compressions which may increase atrial and venous pressures in the brain. Researchers are attempting to determine if patient head elevation will improve blood flow to the brain in a way meaningful to patient survival.
Memorable medical director quotes on resuscitation guidelines
"The strength of the evidence for pediatric resuscitation is weak."
— Peter Antevy, MD
"Focus is on getting mom to survive to get the baby to survive. Peri mortem c-section has a clear survival benefit for mom."
— Kathleen Schrank, MD
"The bottom line is active compression-decompression makes a difference in neurologically intact survival."
— Jeffrey Goodloe, MD
"You can generate lots of force with this device (ACD) and there are times you need to be careful … you are not trying to jack-up a car. Use the force gauge to get optimum effect of the device."
— Joe Holley, MD
"Standard CPR is inefficient by its very nature and completely reliant on chest wall recoil. ACD CPR was much easier to teach than standard CPR during the trial (ResQTrial)."
— R.J. Frascone, MD
"The optimal angle (for heads-up CPR) seems to be about 30."
— Paul Pepe, MD, MPH
Key takeaways on out-of-hospital cardiac arrest resuscitation
Here are key takeaways for medical directors and field providers from the five presentations.
The available evidence, as well as the strength of that available evidence, makes it difficult to make practice changing decisions for pediatric resuscitation.
Cardiac arrest during pregnancy
Continuous manual left uterine displacement — either pushing or pulling — to relieve aorto-caval compression which improves pre-load and after-load is necessary during resuscitation and after ROSC.
Active compression device
- When implementing ACD-ITD, a single CE training is not enough. Medics may not have enough cardiac arrest patients to retain and maintain ACD skills, especially the application of force, which are different than standard CPR compressions.
- Negative airway pressures during CPR with an active compression device and intrathoracic device are increased. The FDA has said "this device is indicated for use as a CPR adjunct to improve the likelihood of survival."
- Head-elevated CPR with an impedance threshold device improves blood flow to the brain during mechanical compressions in laboratory, swine, and cadaver testing.
- Initial implementation by Palm Beach Fire Rescue shows heads-elevated CPR is feasible and with other CPR response improvements patient survival is increasing.
Visit GatheringofEagles.us to view the presenter's slides.