The RFD has been using the AutoPulse
automated CPR device since 2009. The gen-
eralized research on automated CPR devices
hasn’t shown significant benefit in patient
outcomes with their use. 3 Research con-
ducted in 2015 illustrated ROSC rates to be
5% higher for all non-traumatic adult cardiac
arrest patients in Rialto with use of automated
CPR vs. manual CPR
However, it was when evaluating the
use of automated CPR devices
that the RFD had its first eureka
moment—a moment that would
set the stage for the data-driven,
outcome-oriented cardiac surviv-
ability tools that would follow.
The RFD was using automated
CPR in the same fashion it had previously used manual CPR—with
too many pauses in compressions.
Today, the RFD goal is to initiate
and maintain continuous, uninterrupted compressions as soon as possible after patient contact, effectively
maintaining a 100% compression fraction rate
within the first 30 seconds of the resuscitation.
In practice, RFD crews will initiate manual CPR, transition to the AutoPulse device
within 30 seconds and then never turn off
the device; not for intubation, defibrillation,
rhythm checks or pulse checks.
Under RFD’s cardiac arrest protocol, the
automated CPR device can only be turned off
for two reasons: termination of resuscitation
efforts or if ROSC is achieved, as noted by a
precipitous and persistent increase in end-tidal
carbon dioxide (EtCO2).
To ensure compliance with the Cardiac
Survivability Tools, the RFD uses software
(Image Trend ePCR report writer and ZOLL
Case Review) to review all sudden cardiac
arrests. Each compression, ventilation and
all vitals are represented for the duration of
the resuscitation in the program.
Those patients that achieve ROSC share an
extended period of uninterrupted high-quality
CPR as the underlying factor. Although
patients in shockable rhythms generally
achieve ROSC as a result of defibrillation,
those who achieve ROSC from non-shockable
rhythms generally have no discernable causal
intervention other than the absence of breaks
in CPR for several minutes prior to ROSC.
APNEIC OX YGENATION
For years, paramedics have been taught that
30 seconds is all the time they have to establish an advanced airway, or the intervention
should be delayed and a round of pre-oxygen-ation ventilations should be instituted. Apneic
oxygenation allows for passive oxygenation of
a patient that’s already receiving continuous,
uninterrupted compressions, capitalizing on
the low tidal volume but high minute volume
of ventilations generated by the automated
CPR device. 4
The RFD goal for this survivability tool is
to initiate and maintain continuous oxygenation of patients from the time that continuous,
uninterrupted CPR by automated CPR device
is initiated until an advanced air way is secured.
In practice, crews place a nasal cannula on
the patient at 15 liters per minute immediately
after initiating the automated CPR device.
Providers can readily assess the effectiveness of apneic oxygenation through the use of
pulse oximetry. The patient should maintain
or improve their oxygen saturation and EtCO2
levels even when providers aren’t ventilating
the patient to secure an advanced airway.
Applying this tool supports the entire process by avoiding interruption of CPR to secure
an advanced airway and eliminates arbitrary
time standards to secure the advanced airway based on the need to maintain patient
The RFD uses the ResQPOD ITD, a non-
invasive device that delivers intrathoracic
pressure regulation (IPR). The ITD acts as a
one-way valve allowing oxygen to be delivered
during ventilations but restricts ambient air
from entering the thoracic cavity during the
recoil phase of chest compressions and between
ventilations. This lowers thoracic pressure, cre-
ating a vacuum which pulls more blood back
to the heart, increases preload and decreases
intracranial pressure (ICP), allowing for quality
cerebral perfusion. It’s a blood in, blood out
equation. Studies have shown that the ITD
increases blood flow to the heart by 25% and
increases cerebral perfusion by 50%. 5–7
The RFD goal for this survivability tool is
to increase cardiac and cerebral perfusion by
initiating and maintaining the use of the ITD
from the time an advanced airway is secured
until ROSC is achieved. In practice,
crews place the ITD inline of the
ventilation circuit immediately after
verifying placement and security of
the advanced airway.
The RFD hasn’t found a definitive indicator that the ITD is
providing increased circulation.
However, for patients who subsequently achieve ROSC, there’s generally noted improvement in EtCO2
from the time of ITD placement.
This improvement in EtCO2 occasionally occurs rapidly and, in several cases, has precipitated ROSC without
Performing heads-up CPR, with the patient’s
head and torso in a 30-degree elevated position, has been found to optimize perfusion in
the shock state of cardiac arrest. It’s a simple,
yet effective way of decreasing ICP, increasing preload and enhancing post ROSC neurological function. 8
By elevating the head to a 30-degree angle,
venous pressure is relieved and allows gravity
to drain blood back to the heart. Decreasing
ICP and increasing preload allows for more
blood in and more blood out of the brain.
From an ergonomic and effectiveness perspective, heads-up CPR can only be performed
with an automated CPR device and should
only be performed with an ITD in place to
maximize the pressure variant and cerebral
perfusion. Heads-up CPR has a synergistic
effect when provided as a concomitant therapy to the ITD. 9
For heads-up CPR, the most recently
implemented cardiac survivability tool, the
goal is to initiate and maintain heads-up CPR
from the time the I TD is placed until ROSC
is achieved. In practice, once the automated
CPR device is in place, crews move the patient
onto the stretcher and then raise the head of
the gurney to a 30-degree angle.
Patients that achieve return
of spontaneous circulation
share an extended period of
CPR as the underlying factor.