Active compression-decompression cardiopulmonary resuscitation — Instructor and student manual for teaching and training

resuscitation

Resuscitation 32 (1996) 203-212

Active compression-decompression cardiopulmonary resuscitation - Instructor and student manual for teaching and training Part I: The Workshop* Thomas Schneider* a72,Lars Wik bc,2 Other participants: Michael Baubinh, Burkhard Dirks’, Klaus Ellinger’, Terry Gisch’, Torben Haghfelt’, Patrick Plaisanced, Kathy Vandemheen” ‘Johannes Gutenberg University, Department of Anaesthesiology, D-55101 Mainz. Germany bNorwegian Air Ambulance, Department o/Research and Education in Acute Medicine, N-1441 D&k. Norway, cUllev&l University Hospital, Institute /or Experimental Medical Research, N-0407 Oslo, Norway dHopifal Lmiboisiere. Department of Anaesthesiology and Reanimation, F-75475 Paris Cedex IO, France ‘Ottawa Civic Hospital, Clinical Epidemiology Unit. Ottawa, Kl Y4E9 Ontario, Canada ‘O&nse University Hospital, Department of Cardiology B, DK-5000 O&nse C, Denmark gKlinikum Mannheim. Institute for Anaesthesiology and intensive Medicine, 06813.~ Mannheim. Germany htiopold-Franzens-University, Department of Anaesthesiology and intensive Medicine, A-6020 Innsbruck, Austria ‘St. Paul-Ramsey Emergency Medical Services, St. Paul, MN 5S101-2595, USA j Ulm University Hospital. University Clinic for Anaesthesiology, D-89075 U/m, Germany

Received 13 November 1995;revision received 1I May 1996;accepted I3 May 1996

Abstract In an attempt to standardize the teaching and training of active compression-decompressioncardiopulmonary resuscitation (ACD-CPR), a group of leading emergencyphysicians, cardiologists, anesthesiologists,paramedicsand nurses with practical, theoretical, educational, and scientific experience in the subject met in June 1995.The group wa8 calbd The International Working Group of Teaching and Training Active Compression-DecompressionCPR. The group was ‘born’ as a result of the first International Conference of Active Compression-DecompressionCPR held in Copenhagenin March 1995.The following paper describesthe background, development and text of and ACD-CPR course manual for both students and instructors. Keywords:

l

Active compression-decompression;

CPR; Teaching; Training; Course

Corresponding author. ’ Part II follows afkr this. 2 For the first ACD-CPR training workshop.

030@9572/%/515.00 0 1996 Elsevier Science Ireland Ltd. All rights reserved PI1 0300-9572(96)00946-X

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1. Introductioll

A unanimous closing statement of the first European prehospital ACD-CPR workshop was that ‘appropriate ACD-CPR training must precede its implementation’ [l]. However, with the method itself still being under evaluation in clinical trials it is unclear what makes training in this method ‘appropriate’. The only available objective data mainly concern the effect of ACD-CPR upon the provider’s cardiovascular and metabolic status [2,3]. As a first step in overcoming the lack of information and data concerning training in ACDCPR, representatives of nine centres (Europe, 7; USA, 1; Canada, l), involved in studies on ACDCPR gathered for a workshop. Goals of this workshop were (1) to share the different experiencesin training of the ACD method, (2) identify problems with the method when using (Ambu International, the CardiopumpO Copenhagen, Denmark), and (3) eventually create a uniform course concept for training and teaching ACD-CPR. 2. Methds

In addition to the topics discussed at the workshop itself, data acquired by meansof a questionnaire were used to achieve the above mentioned goals. The questionnaire was filled in by each participant and was returned after the workshop was over. 3. Results 3.1. Different training concepts

All of the nine participating centres have been involved in studies concerning ACD-CPR. Therefore, first training sessionswere held by the staff initiating and supervising the ongoing studies. At 4 centres they created course manuals, at 2 centres videos were produced. Three of nine centres had formal instructor training sessionsprior to the introduction of provider courses, the content of these instructor courses being intensified provider courses, with pathophysiological and didactic background information added to the standard course concept. Training concepts con-

sisted of both theoretical (ranging from 20 to 60 min) and practical parts (hands-on training from 15 up to 150 min). Minimal course duration was 60, maximal 180 min. In most courses, the theory:practice ratio was 1:2 to 1:3. In two centres, objective criteria for correct performance existed, put up by the local study directors. Formal testing with pass and fail criteria was performed in three centres. In all nine centres, the built-in gauge of the CardiopumpO was the only device for measuring the force applied during ACD-CPR. Using the pump kneeling beside the patient was considered standard by all nine centres,4 of them teaching the standing position additionally. In this position the person performing ACD CPR stands astride of the patient, with a bent back, looking into the patient’s face. The number of providers trained by one instructor ranged from 2 to 15. In 6 centres, 2 trainees shared one training mannequin. In the other centres, the mannequin:trainee ratio ranged up to 1:8. 3.2. Qualification of instructors

In all 7 European centres, physicians with experience in emergencymedicine trained both instructors and providers. In the US American and the Canadian centre, registered nurses or ALS paramedics with BLS instructor license were the trainers. 3.3. Qual$cation

of trainees

Medical professionals, such as physicians, nurses,paramedics,and EmergencyMedical Technicians were trained in ACD-CPR in all nine centres. In the US American and the Canadian centre, policemen and firefighters were also trained additionally. 3.4. Problems Cardiopump 0

with

ACD-CPR

using

the

During training sessions,three specific problems occurred. The suction cup of the CardiopumpO often did not adhere to the training mannequins’ chestswhen placed on the midstemum land mark. This problem seemsto be independent of the type of mannequin as it appeared with all mannequins

T. Schneider.

L. Wik et al. / Resuscitafion

used, including the Ambu Man@, Ambu CPRPal@, and the Laerdal Resusci Anne@ (Laerdal, Stavanger, Norway). One of the participants reported that in some mannequins proper suction could be achieved by placing the pump upon a landmark that is one or two centimeters higher than midsternum which is not the proper landmark. A standard mannequin is not suitable for proper ACD-CPR training as it is lifted up with every decompression. So either a special mannequin (Ambu CPR-Pal@) has to be purchased or already available standard mannequins have to be modified in order to keep them down on the floor during decompression. Adherence of the suction cup turned out to be a problem in obese patients, women with large breasts, patients with chest abnormalities, bodybuilders, patients covered with sweat, vomit or defibrillation gel, and in presence of pacing or defibrillation electrodes.Repeated attempts to readjust the cup in these patients may delay effective CPR. Instructors from five of the nine centres reported on fatigue of the providers as a problem during training sessions,as was pain in the wrists. However, they reported that providers felt that this was less relevant in real resuscitation situations. Although built for this purpose, pulling up the pump for active decompressionwas a problem for numerous providers at seven of the nine centres since this is so different from standard CPR. In one centre this observation led to a ‘pull it up’ campaign with retraining of all providers emphasizing the active decompression phase. Centres where EMS personnel are not authorized to declare death on scenereported on a specific problem with CPR in progress during patient transport. During standard CPR many rescuers grab the support railing running across the celling of the ambulance with one hand while performing chest compressions with the other. With both hands on the pump during ACD-CPR they felt unstable during transport. 3.5. Proposals for an ACD-CPR gramme

training pro-

Afl participants of the workshop emphasizedthe need for a uniform ACD-CPR training concept.

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‘05

The different training concepts presented at the workshop lead to the develapaEgntof the course programme presentedin Wik’s manuai (seePart II following). 3.6. Qualification of providers and instructors

Persons taking part in an ACD-CPR provider training should be current in BLS according to international standards no longer than 2 years [4,5]. ACD-CPR instructors should be certified BLS instructors experienced in both standard and ACDCPR during real resuscitation situations. 3.7. Course con tents Basic pathophysiology concerning cardiac arrest and different CPR methods could be presented best in a lo-min video showing similarities and differences between standard and ACD CPR. In the video the ACD-CPR device and the training manikin should be introduced. Strong emphasismust be placed upon the active decompression part of ACD-CPR, not neglecting compression depth and rate according to current guidelines [4,5]. The video should show real resuscitation situations with the ACD-CPR device being operated in both BLS and ALS settings. After the video presentation the ACD-CPR devices should be handed out to the participants. Handling of the pump, specific problems and trouble shooting, as well as inclusion and exclusion criteria should be explained. The following problems must be covered as they may diminish the efficacy of ACD-CPR: - Lack of adherence in obese patients, women with large breasts, patients with chest abnormalities, bodybuilders, patients covered with sweat, vomit or defibrillation gel, and presenceof pacing or defibrillation electrodes - ACD-CPR with a patient placed in a bed or on a stretcher, or in a moving ambulance - Provider fatigue with the need for switching rescuersat least every 5 min Total course duration should not exceed 2 h. Video presentation, introducing the method and the device as well as problems and trouble

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shooting should take 45 min, followed by 75 min of hands-on training in small groups. Group size must be limited to three participants per mannequin, with one instructor training a maximum of three groups. This 9:l provider:instructor ratio is necessaryto insure adequate training. Since there are no formal pass or fail criteria, close observation of each participant is the only way of evaluation. During practical training each participant should perform ACD-CPR in 5-min sequences with individual limits of the physical training status allowing to switch earlier than that (‘switch as soon as you get tired’). Both kneeling and standing position should be ’ taught and trained equally. For out-of-hospital standard resuscitation situations, with the patient placed on the floor, each provider should decide individually which position to use.

Formal written testing is not required. However, it may be useful as a teaching tool. References it1 Wik L, Mauer D et al. The first European prehospital ac-

tive compressiondecompression (ACD) cardiopulmonary resuscitation workshop: a report and review of ACD CPR. Resuscitation 1995;30: 191-202. 121Dirks B, Lubke P, Jakn K et al. Physical stress on the rescuer and precision of CPR manoeuvres: ACD-CPR compared to standard CPR. Resuscitation 1994;28: S27 (abstract). t31 Shulta JJ, Mianulli MJ, Gisch TM et al. Comparison of exertion required to perform standard and active compression-decompressioncardiopulmonary resuscitation. Resuscitation 1995;29: 23-31. 141European Resuscitation Council: (Guidelines for basic life support). Resuscitation 1992;24: 111-121. VI American Heart Association: Guidelines for cardiopulmonary resuscitation and emergencycardiac care. J Am Med Assoc 1992;268: 2171-2302.

Part II: A Student and Instructor Manual’ Lars Wik*b9c*2,Thomas SchncideraY2 Other participants: Michael Baubinh, Burkhard Dirks’, Klaus Ellingerg, Terry Gisch’, Torben Haghfelt’, Patrick Plaisanced, Kathy Vandemheen” aJohannes Gutenberg University, Department of Anaesthesiology, D-55101 Mainz. Germany ‘Norwegian Air Ambulance, Department of Research and Education in Acute Medicine, N-1441 Drabak, Norway cVllev~l University Hospital, Institute for Experimental Medical Research, N-0407 Oslo. Norway ‘Hopital Lariboisiere. Department of Anaesthesiology and Reanimation, F-75475 Paris Cedex 10, France ‘Ottawa Civic Hospital, Clinical Epidemiology Unit, Ottawa, Kl Y4E9 Ontario, Canada todense University Hospital, Department of Cardiology B, DK-SW0 O&nse C, Denmark uKlinikum Mannheim, Institute for Anaesthesiology and Intensive Medicine, 068135 Mannheim. Germany hL-eopoldFranzens-Vniversity, Department of Anaesthesiology and Intensive Medicine. A-6020 Innsbruck, Austria ‘St. Paul-Ramsey Emergency Medical Services, St. Paul, MN 55101-2595, USA jUlm University Hospital. University Clinic for Anaesthesiology, D-89075 Ulm, Germany

1. Intradllction Nearly 90% of all cases of cardiac arrest in adults are due to ventricular fibrillation [l], but Corresponding author. t Part 1 precedes this - The two manuals are similar regarding paragraphs l-3, except that the instructor manual also consists of the text written in italic. Paragraph 3 is only found in the instructor manual. ’ For the first ACD-CPR training workshop. l

the incidence of ventricular fibrillation verified by Emergency Medical Services (EMS) personnel rarely exceeds 60% and less than 40% are defibrillated successfully[2]. Early defibrillation is the single most important factor influencing survival in both out of hospital and in hospital resuscitation, although the majority of patients will receivebasic life support (BLS) techniques of chest compression and ventilation before defibrillation is possible. The better the blood circulation is as a result of the CPR technique chosen,the greater the