CT EMS EXPO SCA SYSTEMS

PAVING THE WAY FOR A STRONGER RESUSCITATION SYSTEM OF CARE

Though the national survival rate for cardiac arrest is in the single digits, some systems are able to achieve a survival rate of 50% or higher from cardiac arrest associated with ventricular fibrillation – the rhythm with the best chance of resuscitation.

How these systems do it, and how your system can do it, is what the next 75 minutes are all about.

PLEASE HOLD YOUR QUESTIONS FOR THE Q&A PERIOD

Be certain to give us your email address!We will forward to you links, toolkits and a widevariety of other useful tools.

WHAT IS AN IDEAL SYSTEM OF CARE?

KAMIN

What Is A “System of Care”

First, Where are We At Currently?

Why Such Variability in Survival ?

• In large part, due to differences in the system of care – Incidence of bystander CPR– Dispatch CPR instructions– Community AED’s – Timely EMS response– Specific community practices

for activation of 911• The SYSTEM of care

surrounding OHCA may have some responsibility for the survivability

Baker et all Resuscitation, 2008

Let’s Think About the Pieces of the System

Prehospital• Early Access to 911• Layperson training in CPR• Public Access Defibrillator (PAD)

programs• EMD assisted chest compressions• First responder defibrillation – BLS• ACLS

In-Hospital• Early, goal directed therapy• Therapeutic hypothermia• Early PCI• Implantable Cardiac Defibrillators

The EMS Side: Save A Life – Restore Spontaneous Circulation #1

EVERYTHING we do should promote forward flow of blood

ANYTHING that interrupts forward blood flow should be critically evaluated

Model EMS System of Care #1

1. Establish a Registry – Measure your starting point

2. Improve Layperson Involvement– Layperson Chest Compression Training– Implement Dispatcher Assisted CPR

3. Improve EMS Performance – Implement High Performance CPR/CCR

4. Decrease Time to Patient Access– Implement Rapid Dispatch

Model EMS System of Care #2

5. Voice Record All Resuscitations

6. Police (early) Defibrillation

7. Establish Public Access Defibrillation Program

8. Supplemental Funding and Support for Training and QI

9. Work Toward A Culture of Excellence

15 ISSUES IN RESUSCITATIONQUALITYTHAT FRACTURETHE CHAIN OFSURVIVAL

HILTZ

ISSUES

RESUSCITATE

1. TABLE 2 FROM PREVIOUS SLIDE2. IGNORING THE ISSUES WON’T MAKE THEM GO AWAY3. CAN’T IMPROVE IT IF WE ARE NOT MEASURING IT4. DELAYS/INTERRUPTIONS ARE REAL KILLERS5. IT TAKES A SYSTEM TO

SAVE A LIFE

RESUSCITATION SCIENCE REVIEW

GELLER

TIME IS ALL

• Life is measured in years, death is eternal, the difference between them is 10 minutes.

• Brain death occurs w/in 8 -10 minutes following collapse.

Why Is Time So Important in the Success of CPR ?

• There is no blood flow to the heart and brain, the 2 critical organs. Without blood flow there is no oxygen exchange or energy transfer .

• Cardiac arrest is the ultimate time sensitive medical condition.• Ca.• Cardiac arrest is the ultimate time sensitive

Cummins RO. Annals Emerg Med. 1989;18:1269-1275.

Resuscitation Success vs. Time

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Time (minutes) after sudden cardiac arrest

Chance of successful resuscitation falls 7 - 10% each minute

Time to Arrival of EMS

• In a recent retrospective article from North Carolina with 599 cardiac arrest patients every minute of delay in the arrival of EMS led to a 8 % decrease in the likelihood of a shockable rhythm. Again…7-10 % per minute.

Three-Phase Model of Resuscitation

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Arrest Time (min)

CirculatoryPhase

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MetabolicPhase

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Myocardial ATP

Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8

The initial phase of a cardiac arrest is responsive to defibrillation. The response is very time sensitive

Casinos and vf arrests

• Survival rate 74 % in patients who received first shock within 3 minutes

• Survival rate 49 % in patients who received first shock after 3 minutes

• Intervals of no more than 3 minutes from collapse to defibrillation are necessary to achieve the highest survival rates

Wouldn’t it be nice if we had a simple, acceptable way to extend the electrical phase

of VF arrest ?

There is!Perfuse the heart and it will continue to fibrillate

Prevalence of VF on arrival of EMS in Out-of-Hospital Cardiac Arrest in Arizona

• Not witnessed 16%• Witnessed but no bystander CPR 36%• Witnessed and bystander CPR 52%

Data from 1,296 cardiac arrest in ArizonaVoluntary reporting SHARE Program

Data collected October 2004 to April 2006Bobrow, Clark, Ewy, Kern, Sanders

So What if the Patient is Still in Vfib?

• Thus with chest compressions the cardiac arrest victims will be far more likely to remain in ventricular fibrillation , and not deteriorate into asystole . This is the key to higher rates of survival following cardiac arrest.

• YOU WILL SUSPEND DEATH!!!

Importance of Continuous Chest Compressions

• Chest compression only CPR early in cardiac arrests is more effective than is CPR that includes stopping to give breaths. The key is continuous compressions and anything that interferes with chest compressions is harmful.

• There is a rapid decline in survival without chest compressions. You die at a rate of 10 % per minute without chest compressions.

Cardiac Output and Chest Compressions

• The previous slide reveals that with perfect CPR the best cardiac output we can achieve is 15 %- 21 %. It is not very much, but it is enough.

The Key

• Push hard [to 2 inches]• Push Fast [100 per minute]• Recoil [get your hands off]• And • Don’t Stop [for 2 minutes]

Push Hard•Where is the data

Deeper Sternal Displacement Improves Blood Flow

Babbs. Ann Emerg Med. 1983;12:530.

Relative peak blood pressure and “cardiac output” in anesthetized dogs during CPR

cm of sternal displacement

Organ Blood Flow During Optimal Chest Compression

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Brain Heart Kidneys Intestine

Achievable bloodflow, percent ofnormal

Typical flow inhumans duringCPR

Voorhees W. Crit Care Med 1980;8:134

Tissue flow in anesthetized dogs during optimal ventilation and chest compression.

• The deeper you compress the higher the cardiac output. The key is 5 cm, 2 inches, even in children [the AHA states that in children compressions should be 1/3 the AP diameter of the chest approximately 2 inches!].

• Where is the data ?

PUSH FAST

Higher Rate of Chest Compression= Better Outcome

97 in-patients at 3 hospitals in Chicago, mostly in the ICU.

Abella B. Circulation. 2005;111:428-434.

Inpatient cardiac arrest patients at the University of Chicago

The Key on Rate

• The previous slide , from an ICU in Chicago , reveals 2 things , one is that ROSC [return of circulation, and therefore survival ] is directly related to the rate. The ROSC at a rate of 60 compressions per minute is only ¼ as high as the rate of ROSC at 100 compressions per minute.

• The other very important bit of data is that when the compression rate exceeds 120 the rate of ROSC declines. You must maintain a rate of 100.

Don’t Stop Continuous Compressions

Where is the data?

During cardiac arrest, chest compressions are the patient’s heart beat

Therefore, one needs to assure near continuous chest compressions!

Compression fraction and survival• CPR Fraction 75% Odds Ratio 2.4• 70% 3.4• 65% 5.3• 60% 7.9• 55% 11.1• With a compression fraction of >80 % survival is 11 times greater

than with a compression fraction of 55 %... The ration seen in the study by Valenzuela . The typical fraction in arrests has been 60 %.

The Key [again]• The previous slide makes it clear that the compression fraction ,

how continuous your chest compressions are, determine your survival. If your compression fraction is >80 % your survival is 11 times more likely than with a compression fraction of 55 % [essentially , you are compressing only half the time ]. This slide basically shows a straight line of survival with the continuity of chest compressions . DON’T STOP CHEST COMPRESSIONS. They are the patients only heart beats.

RecoilYou must get your hands off the chest as you do compressions.

Where is the data?

Get Your Hands off the chest and ALLOW RECOIL

Blood flow to the coronary arteries only occurs in diastole. Diastole occurs when the heart is relaxing and is finished with its compression. This corresponds to when you let up from a chest compression, “RECOIL”. If you maintain your hands on the chest during recoil there is inadequate blood flow to the coronary arteries. Blood flow to the brain [and the rest of the body] occurs when the heart squeezes out blood during your chest compression. THUS FOR GOOD BLOOD FLOW TO THE BRAIN AND THE HEART YOU MUST DO A HARD CHEST COMPRESSION AND THEN ALLOW RECOIL.

Intubation and Cardiac Arrests in 2014

There is now compelling laboratory and clinical data that are persuasive for the proposal that intubation be delayed for at least 8 minutes in a cardiac arrest.

Disadvantages of Ventilation During CPR:

• Delays/interrupts chest compressions• Stops bystanders doing CPR?• Gastric inflation – aspiration• Increased intrathoracic pressure• Reduces coronary/cerebral perfusion• worse outcomes

• There is a lot of data that hyperventilation is harmful in cardiac arrests. There is a lot of data that any interruption in chest compressions is harmful. If intubation will be done , it must not interrupt chest compressions and ventilation cannot be allowed to be too frequent [the AHA recommends 6-8 per minute] .

TIME IS ALL



WHO OWNS THE RESPONSIBILITY?KAMIN

A PROBLEM WITHOUT AN OWNER-FREE / OBO-

SUDDEN CARDIAC ARREST

LET’S TAKE A BALLOT!SHOULD EMS “OWN” OOH

SCA?YES or NO

DISPATCHER

CPR!HILTZ AND GELLER

Telecommunicator CPR

• Key to saving lives is quickly recognizing that a cardiac arrest has occurred and to initiate Hands Only CPR in the shortest possible time

TIME IS ALL


• Cardiac Arrest is a critical, life-threatening emergency!




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Six Seconds

• That means that EVERY 6 seconds will KILL 1% more people ! Think about that when you ask more questions.

Why Is Time So Important in the Success of CPR ?

• There is no blood flow to the heart and brain, the 2 critical organs. Without blood flow there is no oxygen exchange or energy transfer .

It is a Problem With the Heart!

• In cardiac arrest the heart stops pumping effectively. The lungs are normal. There is no problem with oxygen. The problem is cardiac and not pulmonary.

The Importance of Dispatch CPR

• In the first 5- 10 minutes of most cardiac arrests EMS is not available . For the bystander who calls in the arrest the dispatcher has the opportunity to provide instructions in CPR that will prolong the ventricular fibrillation phase and allow EMS to arrive with a high likelihood of a successful resuscitation.

• WE WILL SAVE MORE LIVES.

MA State Law on Dispatch

The 911 service must have a Medical director. The service must do Quality Assurance [Q/A ] on its calls, and it must offer dispatch CPR over the phone to callers.I will offer some ideas on Q/A .

The state of Massachusetts follows the guidelines of the American Heart Association [AHA ] . The AHA offers clear guidance onDispatch CPR. I will present their policy.

AHA AND DISPATCH CPR

“CPR instructions for performing Hands Only CPR enable the rescuer to start compressions on average a minute

sooner than conventional CPR. “

“Delaying the initiation of chest compressions while trying to determine

the precise cause of the arrest is suboptimal”


“ In nearly half of all cases in which dispatchers provide CPR …instructions , the patient will not be in arrest. Serious injury from bystander CPR is uncommon [1-2%], but failure to provide bystander CPR to people in cardiac arrest can be

lethal…


• “The balance greatly favors beginning CPR whenever a patient is determined to be unresponsive and not breathing ,OR NOT BREATHING NORMALLY.”

Why Does This Issue Matter?

• Multiple studies have shown that bystander initiated CPR will double or triple the rate of survival from a cardiac arrest.

• The chance of survival decreases by 7-10 % for every minute that no CPR is performed.

• With Hands Only CPR it is 2% per minute

• We must increase the number of people who will perform bystander CPR

• WE WILL SAVE MORE PEOPLE!

Agonal Respirations

The Caller Interview

The Two Critical Questions:

• Is the patient conscious?• Are they breathing normally?

If the answer to both questions is “no”, begin Hands-Only CPR

Why not Mouth to Mouth Breathing in Adult CPR ?

Why not Mouth to Mouth Breathing in Adult CPR ?

• If someone tries to give M2M breathing to a patient with a cardiac arrest the most compressions that can be given is 60 /per minute. Giving 30 compressions takes 15 seconds , giving 2 breaths takes approximately 15 seconds as well. A second round of breaths and compressions adds up to 1 minute.

• Eliminating breathing and doing continuous compressions at a rate of 100 /minute will quadruple the ROSC , compared to a rate of 60!

Dispatcher Goals

• Be Fast!

• Be Aggressive!

• Be unafraid!

QA Goals

• Recognition of a cardiac arrest in 75% of cases

• Recognition of the cardiac arrest within 1 minute, followed by the start of compressions

• Provision of dispatcher assisted CPR on all cardiac arrest calls treated by EMS, or the reason why it was not given.

• Provide feedback to dispatchers

Review the following data for every Run

• Was the arrest recognized ?

• Were the 2 Key Questions asked?

• Were agonal respirations recognized [if present]?

• Was cardiac arrest recognized in under 1 minute?

• Were telephone CPR instructions offered, and accepted by the bystander? Do not ask if the bystander is willing, instruct them what to do, people are more likely to follow your instructions when told what to do than when offered options.

Measurement of Critical Variables

• Witnessed?• Time of collapse? • Bystander CPR?• Dispatcher CPR offered?• Dispatch CPR performed?• Time intervals?

Measurement of Outcomes

• In conjunction with EMS QI

• Was ROSC achieved at scene?

• Was ROSC achieved at the hospital?

• Discharged alive with good CPS score?

• Dispatcher is the most important first responder

• Cardiac arrest can be difficult to recognize

• Risk of injury from unnecessary CPR is minimal

• Ask the 2 Key Questions

• Training and QA

EMPOWERING ORDINARY PEOPLE TO DO EXTRAORDINARY THINGS

A PERSPECTIVE ON HANDS-ONLY CPR

HILTZ

Although technology, such as that incorporated in automated external defibrillators (AEDs), has contributed to increased survival from cardiac arrest, no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act. Moreover, to be successful, the actions of bystanders and other care providers must occur within a system that coordinates and integrates each facet of care into a comprehensive whole, focusing on survival to discharge from the hospital.

HIGH DOSE LOW FREQUENCYVS.

LOW DOSE HIGH FREQUENCY?

CPR DISPARITY-HOT SPOTS

IDEAS IN MOTION!

LAW ENFORCEMENT CPR/AED

HILTZ

IMPROVINGACCESSTO AEDS

HILTZ

Researchers at the University of Copenhagen measured cardiac arrest response in the city from 1994 to 2011. During that period, there were 1,864 cardiac arrests in public areas. 30% of victims collapsed within 100 meters of an AED. However, of those AEDs, 53.4 % were inaccessible during evening, night, and weekend hours.

IDEALLY

BUT SOMETIMES…

http://www.channelonline.tv/channelonline_jerseynews/displayarticle.asp?id=510614



PULSEPOINT

1. REDUCING TIME TO SHOCK 2. AEDs DON’T SAVE PEOPLE… PEOPLE SAVE PEOPLE3. VALUE OF ERPs AND REGISTRIES4. TRUE OPEN ACCESS5. IT TAKES A SYSTEM TO

SAVE A LIFE

HIGH PERFORMANCE CPRGELLER AND SPENCER



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Three-Phase Model of Resuscitation

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Arrest Time (min)

CirculatoryPhase

ElectricalPhase

MetabolicPhase

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100%

Myocardial ATP

Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8

The initial phase of a cardiac arrest is responsive to defibrillation. The response is very time sensitive

Wouldn’t it be nice if we had a simple, acceptable way to extend the electrical phase

of VF arrest ?

There is!Perfuse the heart and it will continue to fibrillate

So What if the Patient is Still in Vfib?

• Thus with chest compressions the cardiac arrest victims will be far more likely to remain in ventricular fibrillation , and not deteriorate into asystole . This is the key to higher rates of survival following cardiac arrest.

• YOU WILL SUSPEND DEATH!!!

The Key

• Push hard [to 2 inches]• Push Fast [100 per minute]• Recoil [get your hands off]• And • Don’t Stop [for 2 minutes]

The Key on Rate

• The previous slide , from an ICU in Chicago , reveals 2 things , one is that ROSC [return of circulation, and therefore survival ] is directly related to the rate. The ROSC at a rate of 60 compressions per minute is only ¼ as high as the rate of ROSC at 100 compressions per minute.

• The other very important bit of data is that when the compression rate exceeds 120 the rate of ROSC declines. You must maintain a rate of 100.

• USE A METRONOME!!!!

Don’t Stop Continuous Compressions

Where is the data?

The CIRC Trial

The results of an international study utilising the autopulse and comparing results to

manual AHA standard cpr with over 4,000 patients . The survival was directly related to

the compression fraction.

RecoilYou must get your hands off the chest as you do compressions.

Where is the data?

• For good cardiac blood flow, recoil is key.• When you compress the chest you are forcing

blood out of the heart and essentially mimicking systole. The blood flow goes to the brain and other organs

• When you recoil, your hands come off the chest . You are mimicking diastole and allowing the blood to flow to the coronary arteries.

• DOWN-BRAIN….UP -HEART…

Should Intubation Be a Part of Cardiac Resuscitation?

• There were three papers that examined this question from Los Angeles, Michigan, & N.C. in 2010 with over 3600 patients with out of hospital cardiac arrests. They all suggested that pre-hospital patients who had no attempt at intubation were two to five times more likely to survive.

• In a recent review of over 600,000 cardiac arrests in Japan the patients who had BVM had better outcomes than the patients who had endotracheal intubation. The patients who were intubated had better outcomes than the patients who were ventilated by extraglottic airways. The data from the ROC trial was very similar.

• Recently the CARES database reviewed their data with intubation and the results were similar.

• THERE IS NO DATA THAT INTUBATION IMPROVES SURVIVAL IN PATIENTS WITH CARDIAC ARREST!

• There is a lot of data that hyperventilation is harmful in cardiac arrests. There is a lot of data that any interruption in chest compressions is harmful. If intubation will be done , it must not interrupt chest compressions and ventilation cannot be allowed to be too frequent [the AHA recommends 6-8 per minute, the tidal volume should be 6 ml per Kg] .

• The patient must be treated on scene. Remember every minute results in a 7-10 % loss of life per minute.

• From the preceding slide , the first responder goes to the chest and initiates chest compressions.

• The second responder will place an oral airway , attach the monitor and then initiate an I/O . The first dose of epinephrine should be administered within 3 -5 minutes of arrival.

Summary

• Keep the patient on scene• Push hard 2 inches• Push fast 100-120 /minute , use a metronome• Don’t stop, except to defibrillate every 2 minutes• Recoil…. down saves the brain• up off the chest saves the heart • Delay intubation….Use a capnometer and if the

patient is intubated keep the ETCO2 35-40, never hyperventilate

• PRACTICE makes perfect

RESUSCITATIONQUALITYIMPROVEMENT

SPENCER AND HILTZ

MEASURE AND IMPROVE…CARDIAC ARREST REGISTRIESKAMIN

WHY HAVE A REGISTRY?

You can’t manage, what you don’t measure

IN AN IDEAL WORLD…

WHAT IS INCLUDED IN CARES?

• Demographics• Etiology• Medical Metrics

– Presenting rhythm– Etiology– Time factors– Bystander CPR– ROSC– Outcome

BUT WHAT IF I CAN’T JOIN CARES?

CONTENTS

• CAD or other dispatch data• AED review• ALS review• Hospital outcome• Resources-mycares.net for

language on approaching hospitals for research databases

WE KNOW WHAT YOU ARE THINKING...

LET”S TALK ABOUT HIPAA

DATABASE ANATOMY

• How are you going to get notifications of CA?

• Who will be managing? • Where will you keep

your data? • Is it secure? • Who will have access? • How will you present

your data?

BIG QUESTIONS

• How will you use the data?• How will you deal with

inquiries for the data? • What will be the access for

stakeholders? • Consistency of data and

coding• Sustainability

CT EMS EXPO SCA SYSTEMS

Health & Medicine

Transcript of CT EMS EXPO SCA SYSTEMS