0% 10% 20% 30% 40% 50% 60%
survivability tools (2015)
Use of ResQPOD
and AutoPulse only
Any 2 survivability tools
Any 3 survivability tools
oxygenation; use of an ITD and heads-up
CPR) for a minimum of five minutes prior
to delivering defibrillation.
Case review and field providers have been
able to assess the effectiveness of this practice by a decrease in the number of defibrillated patients that convert into asystole and an
increase in the number of defibrillated patients
that ultimately achieve ROSC.
EXPANDED USE OF CAPNOGRAPHY
EtCO2 levels provide information
that cells are alive and metabolically
active. Waveform capnography can
help verify the continued placement
of an advanced airway, and it can
help guide delayed defibrillation.
Waveform capnography can also
be an indicator of a patient who
may ultimately survive but may
require additional time for resuscitation. The common practice of
terminating resuscitation for an
asystolic patient after two rounds
of medications or 10–15 total minutes may be limiting survivability. The RFD uses EtCO2 to help
guide this decision.
The goal for this valuable tool, which is integrated into the X Series monitor/defbrillator
used by the RFD, is to ensure that patients
who show signs that resuscitation may result
in ROSC continue to receive care unless clinical findings determine otherwise.
In practice, the RFD only terminates resuscitation efforts if the EtCO2 is less than 15
mmHg and trending downward (after confirming that high-quality resuscitation is being
performed with all of the previously noted
cardiac survivability tools).
If a patient has an EtCO2 that’s greater
than or equal to 15 mmHg and is trending
upward, RFD crews remain on scene, providing all of the survivability tools for at least
30 minutes before transporting or terminating resuscitation.
Even providers who were initially highly
skeptical of this requirement have seen positive results. The RFD rate of ROSC for the
initial presenting rhythm of asystole, including
unwitnessed arrests, is 26%. Of those patients,
the average time from arrival of RFD crews
until ROSC is 24 minutes. All of those
patients had an initial EtCO2 greater than
or equal to 15 mmHg. Half of those patients
survived to hospital discharge.
The type, dosage and priority of administration of medications in cardiac arrest has varied dramatically over time. Matching national
standards, local EMS protocols that the RFD
operates under require epinephrine administration as the first pharmacological intervention for all cardiac arrest victims.
Prioritizing the administration of epinephrine has led to other demonstrably more impactful interventions being delayed. 12 To address
this, consistent with local protocol, the emphasis
should be on high-quality uninterrupted CPR
followed by appropriate interventions.
By sequencing the priority of interventions,
it’s likely that epinephrine, when administered,
will be given when the patient is more receptive
to its pharmacological impact: after the patient
has adequate perfusion, resolution of underlying acidosis and with an adequate EtCO2.
The RFD goal for this survivability tool is
to emphasize the activities that are essential
in the initial minutes of resuscitation and to
subsequently defer epinephrine administra-
tion until priority treatments are realized. The
RFD has seen an increase in survival-to-dis-
charge as a result of this sequencing approach.
There’s no magic ingredient to successful cardiac arrest resuscitation. Although
case review has shown increased ROSC
rates associated with application
of all of the RFD Cardiac Survivability Tools, the significant
increase in survival-to-discharge
is due to the implementation of
the whole system rather than a
The RFD’s system-based
approach relies upon a strong quality improvement (QI) and training platform alongside one of the
RFD’s core values: teamwork.
The most impactful QI actions
have come from the RFD establishing post-resuscitation feedback
that alerts providers and department leadership to compliance with the RFD
Cardiac Survivability Tools. This allows for
focused assessment of each incident and aids
in establishing training needs so that small
course adjustments can be made on a regular basis.
So, let’s be clear, what we have been taught
isn’t working! We have to stop doing what
Figure 1: Percentage of patients where ROSC was achieved
The common practice of
for an asystolic patient after
two rounds of medications
or 10–15 total minutes may
be limiting survivability.