In-Hospital Resuscitation: Focus on Effective Chest Pumps, Prompt Shocks

Randy Dotinga

May 28, 2021

The keys to effective resuscitation in the hospital setting include effective compression and early defibrillation, a hospitalist told colleagues. She also urged them to consider mechanical piston compressions and even "reverse CPR" when appropriate.

"We know CPR [cardiopulmonary resuscitation] and shocking are the two biggest determinants of outcomes, so really strive to make those chest compressions really high quality," said Jessica Nave Allen, MD, FHM, a hospitalist with Emory University Hospital, in Atlanta, Georgia. She spoke about best practices in resuscitation medicine at the Society of Hospital Medicine (SHM) 'Converge' 2021 Annual Meeting.

Nave Allen offered these tips about effective resuscitation:

Don't overcrowd the hospital room.

There shouldn't be more than eight people inside the room during a code, she said. If you're the code leader, "make sure that somebody has already started high-quality chest compressions. You want to make sure that somebody is already on the airway. It's usually two people, one person to actually hold the mask down to make sure there's a good seal, and the other person to deliver the breaths."

Two to three people should be assigned to chest compressions, she said, "and you need one or two nurses for medication delivery and grabbing things from the runners. And then you need to have a recorder and the code leader. Everyone else who's not in one of those formalized roles needs to be outside the room. That includes the pharmacist, usually stands at the door if you don't have a code pharmacist at your institution."

A helpful mnemonic for the resuscitation process is I(CA)RAMBO, which was developed at Tufts Medical Center and published last year, she said. The mnemonic stands for the following:

I: Identify yourself as code leader.

CA: Compression, Airway

R: Roles (assign roles in the resuscitation).

A: Access (intravenous access is preferred to intraosseous, per the American Heart Association's 2020 CPR/emergency cardiovascular care guidelines, unless IV access is unavailable, Allen noted).

M: Monitor (make sure pads are placed correctly; turn the defibrillator on).

B: Backboard

O: Oxygen

Focus on high-quality chest compressions.

The number of chest compressions must be 100 to 120 per minute, Allen said. You can time them to the beat of a song, such as "Staying Alive," or with a metronome, she said, "but whatever it is, you need to stay in that window."

The correct compression depth is 2 to 2.4 inches. "That's very difficult to do during the middle of a code, which is why it's important to allow full recoil," she said. "This doesn't mean taking your hands off of the chest: You should actually never take your hands off of the chest. But you should allow the chest wall to return to its normal state. Also, make sure you aren't off the chest for more for 10 seconds whenever you're doing a rhythm check."

Audiovisual feedback devices can provide insight into the quality of chest compressions, she said. For example, some defibrillators are equipped with sensors that urge users to push harder and faster when appropriate. "Studies have shown that the quality of chest compressions goes up when you use these devices," she said.

Don't be afraid of mechanical chest compression.

Although early research raised questions about the quality of resuscitation outcomes when mechanical piston chest compression devices are used, a 2015 systematic review and meta-analysis found that "man was equal to machine," Allen said. "The bottom line is that these devices may be a reasonable alternative to conventional CPR in specific settings."

American Heart Association guidelines state that mechanical compressions may be appropriate in certain specific situations "where the delivery of high-quality manual compressions may be challenging or dangerous for the provider."

According to Allen, "there are times when it's useful," such as for a patient with COVID-19, in the cath lab, or in a medical helicopter.

Move quickly to defibrillation.

"Most of us know that you want to shock as early as possible in shockable rhythms," Allen said. Support, she said, comes from a 2008 study that linked delayed defibrillation to lower survival rates. "We want to shock as soon as possible, because your chances of surviving go down for every minute you wait."

Take special care for patients with confirmed or suspected COVID-19.

"Not surprisingly, the goals here are to minimize exposure to staff," Allen said.

Put on personal protective equipment before entering the room even if care is delayed, she advised, and reduce the number of staff members in the room below the typical maximum of eight. "In COVID, it should be a maximum of six, and some institutions have even gotten it down to four where the code leaders are outside the room with an iPad."

Use mechanical compression devices, she advised, and place patients on ventilators as soon as possible. She added: "Use a HEPA [high-efficiency particulate air] filter for all your airway modalities."

CPR may be challenging in some cases, such as when a large, intubated patient is prone and cannot be quickly or safely flipped over. In those cases, consider posterior chest compressions, also known as reverse CPR, at vertebral positions T7–T10. "We have done reverse CPR on several COVID patients throughout the Emory system," she said.

Debrief right after codes.

"You really want to debrief with the code team," Allen said. "If you don't already have a policy in place at your institution, you should help come up with one where you sit down with the team and talk about what could you have done better as a group. It's not a time to place blame. It's a time to learn."

Allen has disclosed no relevant financial relationships.

Society of Hospital Medicine (SHM) 'Converge' 2021 Annual Meeting: "Pump It, Shock It, but Don't Blow It: Best Practices in Resuscitation Medicine." Presented May 4, 2021.

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