What Did American Ever Do for Resucitation? · What Did American Ever Do for Resucitation? SOL May...
Transcript of What Did American Ever Do for Resucitation? · What Did American Ever Do for Resucitation? SOL May...
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What Did American Ever Do for Resucitation?
SOL May 5, 2017
Adelaide, South Australia
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American Exit - 1776
Freedom to Innovate in Resuscitation
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First Defibrillation of a Human - 1947
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Inventing Modern CPR
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Emergency Medical Technicians
Anesthesia Analgesia 1972; 51: 27-34
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Intensive Care
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Layperson CPR
• Lay people encouraged to learn mouth-to-mouth since 1966
• CPR was a “medical procedure” – MD, RN only • Recommendation to teach both ventilations
and chest compressions to lay people in 1974 [JAMA 1974; Suppl 18: 841].
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Telephone CPR - 1985
Am. J. Public Health 75 (1985) 47e50.
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Public Access Defibrillation – Casinos - 2000
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NEJM 2002; 347: 1242-1246
Public Access Defibrillation – Airports - 2002
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Public Access Defibrillation - 2004
• Train > 20,000 Laypersons
• Increased number who survived after OHCA
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In-Hospital Cardiac Arrest
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http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelines-Resuscitation
• Respiratory distress turns into CPR 20% of the time
• Preventing arrests in non-monitored beds (or non-ICU beds) improves survival
• Frequent reviews and debriefings improves outcomes for a hospital
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Hands Only CPR - 2000
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Systems of Care JAMA 2001; 285: 1164-1171
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Trauma Centers vs. CA Centers Trauma Centers
• Reduce mortality in most injured patients
• Benefit is greatest in centers that treat the most patients
• Increased efficiency and process of care
Cardiac Arrest Center • ?
• ?
• ?
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JAMA 2008; 299:1158-65
Implementation of Cardiac Arrest Systems
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Dallas
Portland
Alabama
Seattle-KingCo
San Diego
Toronto
Pittsburgh
Vancouver
Milwaukee Data Coordinating Center, Seattle
Ottawa
ROC Sites 36,000 EMS personnel 260 EMS & fire services 24 million people 287 hospitals
Resuscitation Outcomes Consortium (ROC)
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2005 2006
2007 2008
2009 2010
2011 2012
2013 2014
2015 2016
Commissioned in 2004
“To conduct clinical trials in cardiac arrest and life-threatening injury”
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2005 2006
2007 2008
2009 2010
2011 2012
2013 2014
2015 2016
HS Shock
HS TBI
Rescue Shock
Rescue TBI
Hypo Resus
PROPPR
TXA
N=895; Annals Surg 2011; 253: 431-41
N=1,331; JAMA 2010; 304: 1455-64
N=192, J Trauma Acute Care Surg 2015; 78: 687-95
N=50; submitted
N=50; submitted
N=680; JAMA 2015; 313: 471-82
Ongoing
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2005 2006
2007 2008
2009 2010
2011 2012
2013 2014
2015 2016
HS Shock
HS TBI
CPR Feedback
PRIMED
Rescue Shock
Rescue TBI
Hypo Resus
CCC
ALPS
PROPPR
TXA
PART
N=13,126, NEJM 2011; 365: 798-806
N=1,586; BMJ 2011; 342
N=895; Annals Surg 2011; 253: 431-41
N=1,331; JAMA 2010; 304: 1455-64
N=192, J Trauma Acute Care Surg 2015; 78: 687-95
N=50; submitted
N=50; submitted
N=23,711; NEJM 2015; 373: 2203-14
N=680; JAMA 2015; 313: 471-82
N=3,026; NEJM 2016; 374: 1711-22
NEJM 2011; 365: 787-97
Ongoing
Ongoing
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2005 2006
2007 2008
2009 2010
2011 2012
2013 2014
2015 2016
HS Shock
HS TBI
CPR Feedback
PRIMED
Rescue Shock
Rescue TBI
Hypo Resus
CCC
ALPS
PROPPR
TXA
PART
N=13,126, NEJM 2011; 365: 798-806
N=1,586; BMJ 2011; 342
N=895; Annals Surg 2011; 253: 431-41
N=1,331; JAMA 2010; 304: 1455-64
N=192, J Trauma Acute Care Surg 2015; 78: 687-95
N=50; submitted
N=50; submitted
N=23,711; NEJM 2015; 373: 2203-14
N=680; JAMA 2015; 313: 471-82
N=3,026; NEJM 2016; 374: 1711-22
NEJM 2011; 365: 787-97
Ongoing
Ongoing
10 RCT completed over 11 years >44, 647 Subjects enrolled
(2 RCT still to be published)
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As long as you start CPR immediately, delivering first shock within first 3 minutes results in similar outcome (N= 13,126)
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Adding an Impedance Threshold Device to standard CPR does not change outcomes (N= 8,718)
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Real-Time Feedback improves CPR performance, but we cannot detect changes in outcomes (N= 1,586)
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In VF that was not terminated with the first shock, administering Amiodarone, Lidocaine or Placebo does not change outcome (N=3,026). Amiodarone and Lidocaine numerically a bit better (< % difference).
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Continuous Chest Compressions are not better than 30 Compressions: 2 Breaths (N= 23, 711)
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Reasons for Deaths
• Most common (70%) cause of death in ROC cohorts
• ~60% with withdrawal of life support (WLST)
• Median: 2 days
0
10
20
30
40
50
60
70
Perc
ent o
f Cas
es • Understanding
“Proximate Cause of Death” is essential.
• Should have also measured prognostic workup, testing, advanced directives.
Callaway et al. Resuscitation 2014; 85: 657-63
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Final Outcome
Randomize
Intervention Random Effects 30 Variables
150 Variables
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Circulation 2005; 111: 428-434
JAMA 2005; 293: 305-10 • Monitoring of real CPR in real field conditions
• Learned about disconnect between training and real practice
• Identified major source of variation in outcomes
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• Accelerometer can measure chest compressions
• ETCO2 measures ventilation
• Impedance is backup
• CPR Feedback – Philips MRX talks / beeps to
remind compliance with CPR guidelines
Measure Q-CPR
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CPR Process Measurements
Compression Rate CPR Fraction = % of time compressions being done Compression Depth Complete Release = Not leaning on patient during upstroke Ventilation
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>45-50 mm
100-120 / min
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Circulation 2013: 128:CIR.0b013e31829d8654
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Measure CPR Quality
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Pre-ROC Terminology
• Hands-off time • No flow time • Cardiac arrest of cardiac etiology • Major trauma • “Neurologically intact survival” (CPC)
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ROC Terminology
• EMS-assessed Cardiac Arrest • EMS-treated Cardiac Arrest
• “Presumed Cardiac Cause” No Obvious Cause • CPR Process Measures • Chest Compression Fraction
• Functionally Favorable Survival (MRS)
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Size and Shape
Not American
American
Diverse Population of United States
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ROC (2005-7) Survival
02468
1012141618
Assessed Treated Japan
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Compare ROC (2005-7) Survival
02468
1012141618
Assessed Treated
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What is going on in Seattle?
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Seattle’s Contributions
Tachydysrhythmia
Willingness to Act
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Secret Sauce – Resuscitation Academy
• 1000 details – All are important – No single thing can improve outcome by itself – Variation ~ Systems
AED; Time to Call; Dispatch Delays; Wheel Stop to Patient time; BLS/ALS; Number of Providers on Scene; CPR Fraction; Airway; Ventilation Rate; Time to IV; IV/IO; Pre-shock Delay; Peri-shock Delay; Coronary Angiography; Cardiac Arrest Receiving Hospital; Withdrawal of Life Sustaining Treatment
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Feedback during Research Trial
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CPR Fraction during ROC Clinical Trial Participation (Pittsburgh)
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Low-Dose / High-Frequency Training
• RQI – Now
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Smartphone and Apps - 2007
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Invented Things - CPR, ICU, EMT - Layperson CPR Measured Things - Quality of CPR - Why People Die - In-hospital Events Developed Education and Training - Guidelines, Smart Phones - Continuous Training - Hollywood Novel Ways to Improve Delivery - Telephone CPR - AED
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