Evidence-based Analysis Of Cardiopulmonary Resuscitation Essay.

Positive and negative aspects of the video scenario

Discuss About The Evidences On Cardiopulmonary Resuscitation.

The prediction of cardiac arrest in patients who are admitted in hospital is poor and quick medical attention is required for increasing their chances of survival. Mortality due to cardiac arrests is a major problem each year and it occurs due to insufficient resuscitation or delay in resuscitation process. The responsiveness of the code team and their immediate action plays a role in increasing the chances of survival (Clarke et al., 2016). The effectiveness of their action depends on the sequence of interventions they are performing. The rate of survival is dependent on the early attendance and response from the emergency code team, prompt cardio pulmonary resuscitation, quick fibrillation and advanced basic life support. With this context, the main purpose of the essay is to critically analyze a video scenario related to cardiac arrest scenario and review strength and weakness of skills related to resuscitation. The analysis of the video is done on the basis of ARC guideline (Australian Resuscitation Council). The strength and positive and negative points have been identified and discusses with support from research evidence.

After reviewing the video by Saskatchewan Health Authority (2013), many positive and negative skills were identified. For example, after identifying that the person is irresponsive, the nurse immediately called for Code Blue. To indicate that a patient is having a cardiopulmonary arrest, medical institution use the term Code blue (Ferreira et al., 2015). It is an indication that a patient requires resuscitation and is in need of immediate medical attention. In case of the video, her decision to immediately call for Code Blue was a good decision as the patient was unresponsive. Her action was in relevance with the ARC guideline 8 which states DRS ABCD as the initial steps of resuscitation. The DRS ABCD involved seven steps starting from checking for danger (D), checking for responsiveness (R), sending for help (R), opening the airway (A), checking breathing (B), starting CPR (C) and then defibrillation (D) (Australian Resuscitation Council: Guideline 8, 2018). She checked for danger and responsiveness and sent for help (by calling Code Blue) after she recognized that the patient was unresponsive. According to Avis et al. (2016), During unresponsiveness and breathing problem observed in a patient, the emergency member of blue code team should attend the patient to increase his or her survival rate. Their instant response during this emergency is the most important step to handle severe condition. A clear communication and a prompt action is always required to stimulate a fast response (Knight et al., 2014). The only negative non-technical action taken by the rescuer was that she called verbally instead of pressing the emergency button. Jung et al., (2016) explains that rescuers should avoid calling helper verbally. Rather they can use any alarm call for addressing their needs. This can prevent delay in arrival of the Code Blue Team.

Assessment of airway and breathing before commencing CPR

Another negative point observed in the video was that after calling for Code Blue team, the nurse engaged in doing chest compression without doing assessment of breathing and airways. According to the ARC guideline 4, the assessment of airway and breathing takes precedence over other injuries (Australian Resuscitation Council: Guideline 4, 2018).  Although the nurse accurately followed DRS steps, however she skipped the step of airway and breathing before commencing CPR. In case of cardiac arrest, that absence of respiratory movement is one of the major criteria that should be observed by the members of emergency team (Dalal et al., 2018). According to Debaty et al. (2017), better assessment in case of resuscitation is to check the abnormal breathing pattern or absence of breathing. Gasping and abnormal breathing pattern is generally observed during cardiac arrest that subsides down with time. The recognition of this gasping and hypoxia by the bystanders and emergency medical dispatchers is vital for the proper diagnosis of the arrest (Adams, 2018). According to the ARC guideline 5, rescuers should look for absence or abnormal breathing rate to identify the need for resuscitation (Australian Resuscitation Council: Guideline 5, 2018). However, the rescuer in the video did not looked for movement of the upper abdomen or lower chest, did not assessed escape of air from the nose and felt for movement of air at the mouth and nose.

The next vital step according to the DRS ABCD steps mentioned in the ARC guideline 8 (2018) is conducting chest compressions. According to Rajab et al. (2011), responder should initiate chest compression after activating emergency response system. Chest compression is a crucial activity for successful resuscitation as it increases the chances of survival by generating small but critical amount of blood flow to the heart and brain. Compression of chest restores the blood flow and oxygen perfusion to the brain and other organs (Russo et al., 2017). It is a highly standardized technique where proper patient positioning, hand posture, compression rate, compression depth and rotation determine the success of the method. Throughout the video, many negative and positive points related to techniques used for chest compression has been identified. The positive point was that the rescuer started chest compression immediately after calling for Code Blue. The rescuer’s action was in accordance with the ARC guideline 8. The benefit of this action was it minimizes any chances of delay in compressions. Li et al. (2013) states that delay in starting compression lead to grave consequences for patient. Hence, initiating chest compression as early as possible is effective in reducing to increase survival chance of cardiac arrest patient.

Appropriate patient positioning and posture while performing CPR

In this section, negative and positive points related to the techniques uses for chest compression in the video have been highlighted. The first vital technique for successful CPR is appropriate patient positioning and posture while performing the procedure. In the video, the positive skills observed were that the rescuer maintained supine position of patient after observing that the patient was irresponsive. She lowered the height of bed, places the patient in supine position and stood beside patient’s bed while conducting CPR.  A backboard was also placed below the patient during the early phase of CPR. This was a good step taken by staffs because placement of patients on a hard surface before resuscitation favored optimal transfer of energy during the chest compression process. Rajab et al. (2011) explains such step minimizes waste of compressive force because of the soft surface of the hospital bed. The compression should be done after tilting patient’s head backward that results in the opening up of the airway (Idris et al., 2015).

Another positive aspect found in the video was that for appropriate hand posture and hand position was maintained by the staff. She placed the dominant hand over the center of the patient’s chest and it was aligned with the long axis of the sternum. This was a positive skills demonstrated during CPR because it minimizes chances of rib fractures by placing compressive forces on the sternum. While performing CPR, it is necessary to overlap both hand and maintain a parallel position. The same position was maintained by the rescuer too. The arms were straight and elbows fully extended. The advantage of this technique was that it helped in getting maximum mechanical advantage. Evidence also supports the fact that for an effective compression to happen the depth of compression should be 5 cm and the hands of the compressor should be extended while giving compression (Stiell et al., 2014).

The quality of chest compression is also dependent on minimum interruptions during the procedure and maintenance of 30:2 compression: ventilation ratio. The ARC guideline 8 (2018) set high priority on minimizing interruptions rate during the chest compression and balancing 30 compressions with 2 effective breaths between cycle of chest compression. The guidelines also mention that continuous chest compression should be done within a two minute time frame. At 8: 58, the statement of code captain indicated that the two minute time frame was followed. Kwak et al., (2016) also supports the fact that 30:2 compression: ventilation ratio has been recommended by international guideline to minimize hyperventilation and minimize interruptions. Although recent evident suggest increasing C: V rations, however it may decrease quality of CPR due to rescuer fatigue. The two breaths cycles between cycle of chest compression was maintained, however Another weakness observed in the video was that there were several instances of interruptions during the procedure. The chest compression was stopped for a few seconds during defribillation process and then checking for pulse and blood pressure in between. This deteriorates the quality of chest compression. Less interruptions to CPR during cardiac arrest is required for better outcome of the result. Checking of pulse often take 10 seconds and may delay and interrupt the process, so, this should be avoided. Interruptions can be limited by charging the manual defibrillator during chest compression (Gough & Nolan 2017).

Effectiveness of chest compression

The quality of chest compression may deteriorate with time due to rescuer fatigue. Hence, to address rescuer fatigue, it is necessary that compressor is rotated every two minutes.  Another member should take over the responsibility of compression if the first compressor done compression for two minutes and more (Yang et al., 20154). The same technique was followed by compressors in the video too. The process was done for 12 minutes and the two staffs alternatively took the chest compression responsibility to minimize fatigue and maintain quality of CPR. This action is in accordance with the ACR guideline 8 (2018) as it emphasized on having multiple rescuers and continuing resuscitation until the person becomes exhausted. Chung, (2017) explains that the change in duty should be done with negligible interruptions since any delay in this process may deteriorate the survival chances of the patient. Hence, the strength of chest compression process as demonstrated in the video was maintenance of desired C: V ratio, optimal position and rescuer fatigue. However, the negative aspects of the chest compression process were brief period of interruptions during the procedure. As per ARC guideline 8 (2018), attaching an automated external defribrillator (AED) is also necessary to after CPR. After arrival of the Code Blue team, AED was applied to patient. Chest compression was paused during defribillation attempt. This was done for rhythm analysis. Deakin and Koster (2016) suggest that this can be prevented by resuming chest compression during defribillator charging or eliminating pulse checks.

Epinephrine is used in cardiac arrest and it is the primary drug to be administered during CPR that reverses cardiac arrest (Lin et al., 2015). The drug was administered to patient in the video too. The drug acts by increasing coronary perfusion and arterial blood pressure during CPR through alpha-1- adreno receptor (Callaway, 2013). However many evidences suggest that adrenalin administered during hypothermic cardiac arrest are responsible for increasing overall cerebral oxygen extraction regardless of an increase in cerebral perfusion pressure (Putzer et al., 2016). It is also associated with poor outcome since it is responsible for the increase in demand of oxygen in heart muscle. Further evidences suggested that epinephrine administration within 2 minutes of first commencement of defibrillation decrease the rate of survival. It is thus recommended to administer epinephrine afterwards (Andersen et al., 2016).

Amiodarone was also administered to patient in the video. Amiodarone is also responsible for improving the survival rate (Laina et al., 2016). In addition, normal saline was provided to the patient during the resuscitation process. Evidence suggested that the efficacy of hypertonic saline solution in cardiopulmonary resuscitation is more as compared to normal saline solution. Meta-analysis showed a considerable increase in the rate of restoration of spontaneous circulation (ROSC), sodium concentration of serum during CPR in case of animal models of cardiac arrest treated with hypertonic saline solution (Li et al., 2015). Cardiovascular disease is also associated with type 2 diabetes mellitus. In order to prevent hypoglycemia, ampoules of dextran 50% can be administered (Fox et al., 2015).

Quality of chest compression

Conclusion:

From the above discussion, it can be that cardiopulmonary resuscitation is a lifesaving technique that can be commenced in an individual during emergency conditions of cardiac arrest. The quick assessment of breathing pattern and the status of patient is essential in order to apply CPR. The first bystander who recognizes the abnormal breathing pattern of the patient should commence the CPR immediately that can increase survival rate. Early compression is required in order to avoid the primary brain damage. Quality and effectiveness of compression is necessary for better outcome. Delaying in action of emergency team can deteriorate the patient’s condition, so, the prompt action and early recognition of abnormal breathing pattern is required for decreasing the chances of survival. Though some drugs like Epinephrine and Amiodarone have some positive effects in cardiac arrest, yet, they fail to elicit any long-term responses in cardiac arrest.

References:

Adams, D. (2018). Long-term prognostic value of gasping during out-of-hospital cardiac arrest: Debaty G, Labarere J, Frascone RJ, et al. Journal of the American College of Cardiology. 2017; 70 (12): 735-1097. Journal of Emergency Medicine, 54(2), 269.

Andersen, L. W., Kurth, T., Chase, M., Berg, K. M., Cocchi, M. N., Callaway, C., & Donnino, M. W. (2016). Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis. bmj, 353, i1577.

Australian Resuscitation Council: Guideline 4, (2018). ANZCOR Guideline 8 – Cardiopulmonary Resuscitation. (2016). [ebook] Available at: https://resus.org.au/guidelines/ [Accessed 23 May 2018].

Australian Resuscitation Council: Guideline 5, (2018). ANZCOR Guideline 8 – Cardiopulmonary Resuscitation. (2016). [ebook] Available at: https://resus.org.au/guidelines/ [Accessed 23 May 2018].

Australian Resuscitation Council: Guideline 8, (2018). ANZCOR Guideline 8 – Cardiopulmonary Resuscitation. (2016). [ebook] Available at: https://resus.org.au/guidelines/ [Accessed 23 May 2018].

Avis, E., Grant, L., Reilly, E., & Foy, M. (2016). Rapid response teams decreasing intubation and code blue rates outside the intensive care unit. Critical care nurse, 36(1), 86-90.

Callaway, C. W. (2013). Epinephrine for cardiac arrest. Current opinion in cardiology, 28(1), 36-42.

Chung, S. P. (2017). Influence of rescuer strength and shift cycle time on chest compression quality. Signa vitae: journal for intesive care and emergency medicine, 13(1), 70-74.

Clarke, S., Apesoa-Varano, E. C., & Barton, J. (2016). Code Blue: methodology for a qualitative study of teamwork during simulated cardiac arrest. BMJ open, 6(1), e009259.

Dalal, Y., Hatlestad, J. D., Zhang, Y., Lewicke, A., & Stahmann, J. E. (2018). U.S. Patent No. 9,943,234. Washington, DC: U.S. Patent and Trademark Office.

Importance of minimizing interruptions during chest compression

Deakin, C. D., & Koster, R. W. (2016). Chest compression pauses during defibrillation attempts. Current opinion in critical care, 22(3), 206-211

Debaty, G., Labarere, J., Frascone, R. J., Wayne, M. A., Swor, R. A., Mahoney, B. D., ... & Aufderheide, T. P. (2017). Long-term prognostic value of gasping during out-of-hospital cardiac arrest. Journal of the American College of Cardiology, 70(12), 1467-1476.

Ferreira, T., Paredes-Aller, S., Farquharson, L., Diaz, Y., Sneij, W., Campo, R., ... & Ashley, D. (2015). C48 RESUSCITATION: INCREASING BENEFIT AND DECREASING HARM: The Impact Of Implementing A Rapid Response And Code Blue Team In An Academic Tertiary Care Hospital With A Hybrid Medical Staff. American Journal of Respiratory and Critical Care Medicine, 191, 1.

Fox, C. S., Golden, S. H., Anderson, C., Bray, G. A., Burke, L. E., De Boer, I. H., ... & Inzucchi, S. E. (2015). Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation, 132(8), 691-718.

Gough, C. J. R., & Nolan, J. P. (2017). Airway and Ventilation During Cardiopulmonary Resuscitation. In Annual Update in Intensive Care and Emergency Medicine 2017 (pp. 223-234). Springer, Cham.

Idris, A. H., Guffey, D., Pepe, P. E., Brown, S. P., Brooks, S. C., Callaway, C. W., ... & Kudenchuk, P. J. (2015). Chest compression rates and survival following out-of-hospital cardiac arrest. Critical care medicine, 43(4), 840-848.

Jung, B., Daurat, A., De Jong, A., Chanques, G., Mahul, M., Monnin, M., ... & Jaber, S. (2016). Rapid response team and hospital mortality in hospitalized patients. Intensive care medicine, 42(4), 494-504.

Knight, L. J., Gabhart, J. M., Earnest, K. S., Leong, K. M., Anglemyer, A., & Franzon, D. (2014). Improving code team performance and survival outcomes: implementation of pediatric resuscitation team training. Critical care medicine, 42(2), 243-251.

Kwak, S. J., Kim, Y. M., Baek, H. J., Kim, S. H., & Yim, H. W. (2016). Chest compression quality, exercise intensity, and energy expenditure during cardiopulmonary resuscitation using compression-to-ventilation ratios of 15: 1 or 30: 2 or chest compression only: a randomized, crossover manikin study. Clinical and experimental emergency medicine, 3(3), 148.

Laina, A., Karlis, G., Liakos, A., Georgiopoulos, G., Oikonomou, D., Kouskouni, E., ... & Xanthos, T. (2016). Amiodarone and cardiac arrest: Systematic review and meta-analysis. International journal of cardiology, 221, 780-788.

Li, H., Zhang, L., Yang, Z., Huang, Z., Chen, B., Li, Y., & Yu, T. (2013). Even Four Minutes of Poor Quality of CPR Compromises Outcome in a Porcine Model of Prolonged Cardiac Arrest. BioMed Research International, 2013, 171862. https://doi.org/10.1155/2013/171862

Li, W., Xu, J., Tan, D., & Yu, X. (2015). The efficacy of hypertonic saline treatment in cardiopulmonary resuscitation in animal model with cardiac arrest: a Meta-analysis.

Lin, S., Sundermann, M. L., Dorian, P., Fink, S., Halperin, H., Kiss, A., ... & Niemann, J. T. (2015). Epinephrine in Cardiac Arrest: A Randomized, Multicenter, Double-blinded, Placebo-Controlled Experimental Trial.

Putzer, G., Braun, P., Strapazzon, G., Toferer, M., Mulino, M., Glodny, B., ... & Mair, P. (2016). Monitoring of brain oxygenation during hypothermic CPR–A prospective porcine study. Resuscitation, 104, 1-5.

Rajab, T. K., Pozner, C. N., Conrad, C., Cohn, L. H., & Schmitto, J. D. (2011). Technique for chest compressions in adult CPR. World Journal of Emergency Surgery, 6(1), 41.

Russo, A., Gasparetto, N., Favero, L., Caico, S. I., Orazio, S., Garzena, G., ... & Olivari, Z. (2017). The use of mechanical chest compression devices for both out-of-hospital and in-hospital refractory cardiac arrest. Giornale italiano di cardiologia (2006), 18(4), 305-312.

Saskatchewan Health Authority. (2013). Code Blue.  Retrieved from: https://www.youtube.com/watch?v=U1zq4T7MEWw

Stiell, I. G., Brown, S. P., Nichol, G., Cheskes, S., Vaillancourt, C., Callaway, C. W., ... & Free, C. (2014). What is the optimal chest compression depth during out-of-hospital cardiac arrest resuscitation of adult patients?. Circulation, CIRCULATIONAHA-114.

Yang, Z., Li, H., Yu, T., Chen, C., Xu, J., Chu, Y., ... & Huang, Z. (2014). Quality of chest compressions during compression-only CPR: a comparative analysis following the 2005 and 2010 American Heart Association guidelines. The American journal of emergency medicine, 32(1), 50-54.