Our Medical Education Platform Expands!

Medical Education

We are excited to announce the newest update to our medical education programs: The new Learning Studio!

During the summer and fall of 2014, Iridia Medical worked on finding a dedicated space to host educational programs. The new classroom is located near our headquarters and is dedicated entirely to our educational programs. With an open classroom design and two breakout rooms for group work, we’ve created an optimal learning environment. Additionally, the space features an office for instructor privacy and a kitchen for student comforts.

The self-contained space is a great example of one of the many innovative advances our Education Department has showcased for the New Year.

Medical Education at IridiaMedical Education Stats

Iridia Medical provides engaging, practical emergency medical training to healthcare personnel and lay rescuers. Rooted in best practices, content is delivered by highly experienced medical professionals, who balance learner skill, knowledge, and experience.

Our courses and workshops meet and exceed all recommendations from:

Medical Education Recommendations

To provide the highest quality medical education, all of our workshops can be customized to meet your organization’s targeted educational needs and booked for private groups across British Columbia.

To view the schedule, please visit our website, www.iridiamedical.com or contact us directly to discuss the possibilities of developing a course specialized for your group and to register for any of our courses below.

 

How ETCO2 may inform vasopressor use!

Consider the following scenario. While in the emergency department a man suffers a witnessed cardiac arrest, for which he receives prompt high quality CPR, 200 joules defibrillation for an initial rhythm of V-Tach. The defibrillation is followed by a further 2 minute round of high quality CPR during which time an advanced airway with minimal interruptions in chest compressions. ETCO2 monitoring is initiated and shows 12mm/Hg. From this resuscitators can see that patient remains without pulmonary circulation and that the quality of CPR is satisfactory. After the 2 minutes, a quick pause in CPR reveals persistent V-Tach on the monitor. Chest compressions are resumed while the defibrillator is charged, the patient is cleared, 200 joules are delivered chest compressions are immediately resumed.


ECTO2

Let’s now consider two different paths that the ETCO2 scenario can take from here:

  • The defibrillation is unsuccessful, and during the 2 minutes of high quality CPR that follow the ETCO2 hovers around 7 mm/Hg. Seeing this low number, the team changes chest compression providers, and a new clinician is able to get the waveform up to 12mm/Hg. In this case, there is no ETCO2 indication of return of spontaneous circulation, and since there remain no signs of life, CPR is continued and as the code progresses the clinicians consider giving IV epinephrine.
  • Alternatively, the defibrillation is successful, and during the 2 minutes of high quality CPR that follow the ETCO2 jumps to 40mm/Hg. In this case there is ETCO2 indication of return of spontaneous circulation, and the team searches for other signs of life, which may include a pulse. Finding none: high quality CPR is continued however this time the decision is made to withhold the IV epinephrine.

The above scenario illustrates how continuous ETCO2 can not only serve to confirm ongoing placement of advanced airways, but can also be used to inform the quality of CPR, illuminate ROSC and help guide vasopressor use during resuscitation attempts. This being said there still remains no evidence that using epinephrine in this way contributes to neurological intact survival to hospital discharge.

Lastly, this practice of ETCO2 monitoring during resuscitation attempts relies on placement of advanced airways, which have been deemphasized in the ACLS Guidelines since 2005. As such we can see how with increased emphasis on ETCO2, the latest Guidelines may result in an increased use of advanced airways. This unto itself is not necessarily a bad thing, as long as we do not do so to the detriment of our patients. When using advanced airways there is an increase in responsibility to not interrupting chest compressions for too long, and to avoid the hyperventilation of our patients with tidal volumes that are too large and ventilation rates that are too excessive.

Darin Abbey RN
Clinical Nurse Educator
Emergency Department
Nanaimo Regional General Hospital

Resuscitation and ETCO2: So what’s the use?

Resuscitation and ETCO2

Remember back in 2005 when it became ACLS Guideline directed practice to resume CPR immediately after defibrillation. Did that freak you out? Do you still pause after defibrillation, and try to sneak a quick peak at the monitor to check for a life sustaining rhythm?  Do you delay chest compressions to quickly feel for a pulse? If you answered, “yes” to either or both of these questions, perhaps you are doing so propelled by a combination of hope and or fear. Hope that your efforts at defibrillation were successful, and fear that your ongoing resuscitation efforts will cause harm. Indeed after defibrillation, the curious practitioner is left to wonder “what if our shock was successful and we obtained return of spontaneous circulation [ROSC], could we cause harm with chest compressions or by pushing IV epinephrine?”  At first glance delaying a rhythm and pulse check can feel like a great leap of faith, and for some members of the resuscitation community this leap represents a significant clinical hurdle to overcome. The 2010 ACLS Guidelines have given us a way to jump over that hurdle and keep on running safely through our resuscitations. In this latest iteration, emphasis has been placed on continuous waveform or capnometric ETCO2 monitoring. Achieved in cardiac arrest by inserting a line onto an advanced airway to a receiving monitor, this metric is used not only for ongoing confirmation of advanced airways, but also provides real time breath-by-breath physiological evaluation of patients. The study of capnography is multi-faceted and as a simplified statement normal values are 35-45 mm/Hg. The waveform below shows a patient with an ETCO2 of 34 mm/Hg: ETCO2 Naturally a pulseless patient, who has no pulmonary circulation, will in turn have no ETCO2. However when high quality CPR is performed, the exhaled ETCO2 jumps from 0 mm/Hg to greater than 10mm/Hg.  If during compressions, the ETCO2 lowers; code team members should turn their attention to the quality of the CPR being given. Rescuer fatigue for instance can dramatically decrease chest compression efficiency. The waveform below shows a patient receiving CPR with an ETCO2 rising from around 10 to 16 mm/Hg: ETCO2 If during high quality CPR there is a return of spontaneous circulation then the ETCO2 will display “an abrupt sustained increase” and as shown below will jump into the 35-45 mm/Hg range. ETCO2 This is how employing the use of continuous ETCO2 monitoring during CPR, that resuscitators are provided with insight into the outcome of their defibrillation attempts and with a window to ROSC. Indeed it is this information that allows clinicians to jump over the hurdle described above, and to gain an increased sense of comfort with the decision to resume chest compressions immediately after defibrillation. CPR

    Darin Abbey RN Clinical Nurse Educator Emergency Department Nanaimo Regional General Hospital

All About Supraglottic Airway… pt. 2

This week I am highlighting two airway discussion points which have recently come to my attention: cuffed vs. non-cuffed endotracheal tubes (ETTs) in pediatric patients and the possible, negative side effects of supraglottic airways.

See my first post on cuffed vs. non-cuffed endotracheal tubes: Part 1

Supraglottic Airways: Help or Harm?

Health Care Providers (HCPs), working in multi-disciplinary, team oriented environments, are able to achieve rapid and early airway management without interrupting resuscitation efforts. However, the role of ETTs has been de-emphasized during cardiac arrest management and HCPs are encouraged to use alternate airway devices, such as supraglottic airways.

Supraglottic airways minimize interruptions in compressions and as a result, maximal blood flow to the brain. Or, so we thought…

A recent swine study shows evidence supraglottic devices may decrease cerebral blood flow in low output states. See the article below.

http://emcrit.org/wee/extraglottic-airways-harmful-cardiac-arrest/

 Supraglottic Airway

In the ACLS courses I instruct at Iridia, I have been strongly encouraging the use of supraglottic airway devices.  Mainly because King Tubes or laryngeal mask airways can be inserted without stopping chest compressions and this allows for more blood to the brain. But, if these airway devices impede blood flow to the brain, should we be using them at all?

What is the future of airway management during cardiac arrests? Will newer, high-tech devices make it to market or will airway management go back to a head-tilt, chin-lift with oxygen from a simple mask?

I’d love to hear your thoughts and opinions. Let me know what you think about these discussion points.

CPR and First Aid Retention – Revisited

Back in October, we talked about CPR and First Aid Skill Retention. At the time, a WorkSafe BC study showed that many of the skills learned in CPR and First Aid courses were forgotten shortly after certification.

First Aid Retention

The WorkSafe study came to these conclusions:

• Many skills deteriorate rapidly over the course of the first 90 days.
• Repetition (the number of times trained/certified in First Aid or CPR) may be more important to skill retention than the length of time since the last training.
• A number of skills were performed poorly regardless of how much time had passed since the last training.
• Simple and cost effective updating strategies for first aid and CPR are needed to reduce the rate of knowledge and skill deterioration.

Their recommendation was to do a refresher course every 90 days, as individuals who repeated certification tended to score higher on exams. Repetition is the key.

First Aid Retention

Now, fast forward five months and it seems that WorkSafe’s initial findings were spot on. In a review of 11 international studies, researchers have found health providers’ skills in advanced life support typically deteriorated six months to a year after training.

Currently, the standard guidelines call for re-training every two years. These guidelines are quoted as “not optimal” by Dr. Lance Becker, director of the Center for Resuscitation Science at the University of Pennsylvania in Philadelphia.

So why do widespread guidelines recommend re-training every two years?

According to Becker, one of the main reasons was convenience; historically the two-year time frame was seen as an easy fit for busy schedules. Another, he said, is the lack of good research showing a shorter interval is necessary.

Without evidence from well-designed studies, it’s hard to change guidelines, Becker noted.

What’s needed, he said, is more research into the best ways to train and retrain people in advanced life support and first aid retention.

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At Iridia we understand the need to provide high-quality training; we focus our training on positive and interactive instructional methods, combined with practical hands-on components.

Please view our ACLS flyer for more information.

Our medical education and instructors are consistently praised for lowering the stress and pressure that many health care professionals associate with Advanced Cardiac Life Support (ACLS) continuing education.

If you are interested in continuing your medical education please visit us, we provide a wide variety of courses from ACLS to basic CPR and AED training and recertification.