EmergencyPedia

Ruthlessly Efficient Defibrillation (RED)

There are 3 key priorities in managing an Adult patient in Cardiac Arrest:

1. Giving Effective Cardiopulmonary Resuscitation (CPR) – The most recent revision of the CPR guidelines (2010) have emphasised the ‘C-AB’ approach in adult patients because interruptions in CPR are likely to lead to a diminished chance of achieving Return of Spontaneous Circulation (ROSC).  Good CPR has been associated with increased liklihood of successful defibrillation.
2. Giving Adrenaline (immediately in non-shockable rhythms and after 2 shocks on the VF/VT side of the algorithim)
3. Early Defibrillation – along with priority ‘1’ has been associated with increased likelihood of ROSC

Of these three key priorities in Advanced Life Support (ALS) only number ‘1’ and ‘3’ have a significant evidence base in terms of increased survival of patients.  Number 2 (adrenaline) has been shown, albeit in an underpowered study, to increase the likelihood of ROSC but not increase the liklihood of intact survival.  While most, if not all, clinicians would not withhold adrenaline, the key priorities must include both Early Defibrillation and Minimising ‘Hands Off’ Time during effective CPR.

These goals can be achieved by improving teamwork and training for ALS providers.  However, monitoring carefully what we do in Cardiac Arrests is important as many studies have shown we often do CPR poorly.  Common CPR problems include:

1. Over Ventilation – rates of over 30 and up to 60 per minute have been seen in studies of CPR
2. Misplaced Endotracheal Tubes – varies considerably between studies.  One study showed a misplacement rate of 19% which may support the a low threshold for using a Larayngeal Mask Airway with End Tidal Co2 attachment in Cardiac Arrest
3. Poor Quality of Chest Compressions – rates often too fast or too slow
4. Significant Delays in Defibrillation – these delays are probably common and may be associated with pulse checks and fixation with monitoring devices.  A randomised trial showed no advantage of delaying defibrillation to allow for a ‘pump priming’ period of CPR prior to DC shock.
5. Team leaders may be unaware of basic errors made by the team performing CPR.
   • To avoid this it may be useful to use a checklist – Click Here

 

As a response to the commonly seen CPR errors listed above the team at Westmead Hospital’s Simulation Lab have been teaching a fast and efficient script for the delivery of early defibrillation in CPR for the last couple of years…  I think it’s a great method that is easy to learn so thought I would share it with you…

While there’s no ideal way to perform ‘Ruthlessly Efficient Defibrilllation‘ we believe the principles are as follows:

(1) R.E.D. Team Drill

• Minimise ‘Hands off Time‘ to achieve “R.E.D.”

  • Practice CPR
    • Using both simulation and mental rehearsal of actions in a cardiac arrest)
  • Training of ALS providers
    • Ensure they are reaccredited on a regular basis (i.e. every 12 months)
  • Communication – use clear and concise communication (see below)

• Use Cognitive Aids during the Cardiac Arrest

  • The COACH mneumonic
  • ALS algorithim

• These Cognitive Aids are very useful for the busy practitioners to free up their thinking and provide a checklist to ensure all the important steps of effective CPR are being done…

The C.O.A.C.H. Mnemonic

(2) R.E.D. Focus on Communication and Teamwork

• Good Communication bettween the Team Members

• Knowledge of Roles in the Team

• Closed Loop Communication

• Use each others names

• Frequent Changes of Rescuers (that are providing CPR) – you get tired in less than two minutes

• Be a good ‘Team Leader’ or good ‘Team Member’

• Have a Knowledge of ‘Human Factors‘ and ‘ Crisis Resource Management (CRM)’

• Every time you experience a cardiac arrest (or near cardiac arrest) debrief with your colleagues and reflect on what went well and what have gone better and how that could be achieved next time

(3) R.E.D. Technical Points

• Use a mechanical device where available (e.g. Zoll AutoPulse) – this is routinely used in Japanese ambulances

• Use a metronome set to 100/min pace (you can download a free metronome on any smartphone) – we have been known to hold up our phone to the CPR rescuers ear during CPR help them get the right pace.  (various songs are also options)

• Use a team member to set the time (I use my own 1980s throwback Casio watch set to a 2 minute countdown which will beep every two minutes to prompt a rhythm check)

• Get an early blood gas to exclude important reversible causes

• Use End Tidal Co2 Waveform Capnography to monitor effectiveness of CPR, aid in prognosis and detect ROSC

The Zoll Mechanical Resuscitation Device

PHOTO

VIDEO

Royal Prince Alfred ICU in Action

(SMACC 2012 Video) 

Despite the Distracting Dramatic Music (courtesy of the UK Hit TV Medical Drama ‘Casualty‘), these guys manage to pull off a good demonstration of the principle of minimising ‘Hands off’ Time and therefore R.E.D.!