mt sinai ccr final.ppt - emcrit project · • ~3,000 emt (b) and (p) trained compliance criteria...

1/8/2009

1

Cardiocerebral Resuscitation: A New Approach to Cardiac Arrest

Bentley J. Bobrow, MD Medical Director

Bureau of EMS & Trauma SystemArizona Department of Health Services

Assistant ProfessorDepartment of Emergency Medicine

Mayo Clinic College of Medicine

Conflict of Interest

Relevant Financial RelationshipsNone

Off Label UsageNone

American Heart AssociationBLS Guideline Committee Volunteer

Sarver Heart Center Resuscitation Research Group

Objectives

• Discuss the keys to successful resuscitation

• Introduce a different approach to OHCA• Introduce a different approach to OHCA

• Define Cardiocerebral Resuscitation (CCR)

• Present the AZ CCR system-wide results

Out-of-Hospital Cardiac Arrest (OHCA)

• Critical EMS function

• Quantifiable EMS function

• Test of entire EMSS

• Surrogate marker for success of EMS

• We can save lives!

Where Can EMS Make A Difference in Outcomes?

• Cancer

• Pneumonia

• AIDS

Kid Di

• Cardiac Arrest

• Major Trauma

• ST-Elevation MI

A S k• Kidney Disease

• Diabetes

• Alzheimer’s

• NOT YET

• Acute Stroke

• YES

In the absence of early defibrillation, until very recently

19741980 20001992

y yOHCA survival rates have not improved

al s

urvi

val (

%) 50

40

30

OHCA Survival

Arizona ‘04

Neu

rolo

gica

lly n

orm

a 30

20

10

0Chicago ‘87 Ontario ‘89 LA ‘00 Seattle ‘01

1 2 1

16

?

Eckstein M et al. Annals of Emerg Med. 2005;45: Issue 5;504-509 Rea T et al. Circulation. 2003;107:2780-2785

Dunn et al. Resuscitation. 2007;72:59-65

Detroit ‘02

1/534

1/8/2009

2

Why is OHCA Survival so Low?

• Poor public knowledge of cardiac arrest• Delayed time to first defibrillation• Low rates of bystander CPRy• Inconsistent quality of professional CPR• Inconsistent post cardiac arrest care

“We have not adequately implemented what we already know works”

Different Approach to OHCA

Since OHCA is a major public health problem:

• We should maximize resources and collaborationsto accurately tracking outcomesy g

• Maybe communities need a customized approach

• Maybe we need a bundled approach

• EPs must lead communities and bridge the gap between current knowledge practice

SHARE ProgramModel for OHCA Collaboration

AHAMunicipal FDs

Public HealthPrivate Ambulance

Local HospitalsPrivate Industry

University ResearchersPublic Safety Officers

Public “Joe the Pumper”

Goal: For Arizona to have the highest survival rate in the world for cardiac arrest victims.

www.azshare.gov

Apache Junction FD Kingman FD River Medical AmbulanceArivaca FD Lake Mohave Ranchos FD Rural MetroAvondale FD Lifeline Ambulance Scottsdale FDBlue Ridge FD Lifestar Ambulance Sedona FDBuckeye Valley FD Maricopa FD Seligman FDChandler FD Mayer FD Sonoita - Elgin FDCentral Yavapai FD Mesa FD Southwest AmbulanceChino Valley FD Montezuma/Rim Rock FD Summit FDDaisy Mountain FD Nogales FD Sun City FDElephant Head Volunteer FD Nogales Suburban FD Sun City West FDEl Mirage FD Northwest FD Sun Lakes FDFlagstaff FD Page FD Surprise FD

73 SHARE Participants

Flagstaff FD Page FD Surprise FD

Gila River Indian Community EMSPatagonia Lake State Park/Sonoita Creek State Natural Area FD Tempe FD

Gilbert FD Patagonia Volunteer FD Tolleson FDGlendale FD Payson FD Tonopah Valley FDGolden Valley FD Peach Springs EMS Tubac FDGoodyear FD Peoria FD Tucson FD

Grapevine Mesa FD Phoenix FDUnited States Border Patrol - AZ

Green Valley FD Pine Lake FD Tusayan FDGuadalupe FD Pinewood FD Verde Valley FDGuardian Medical Transport Pinion Pine FD Walker FDHelmet Peak FD PMT Western Air RescueHualapai Valley FD Prescott FD Yarnell Fire District

Puerco Valley FD Yuma FD6/24/2008

OHCA Survival in Arizona

“With so few survivors, we felt

compelled to make

“With so few survivors, we felt

compelled to make

50

40

Arizona 2004

compelled to make modifications to

protocol based upon current evidence

and track the results closely.”

compelled to make modifications to

protocol based upon current evidence

and track the results closely.”

30

20

10

0

Bobrow et al, Prehospital Emergency Care 2008;12:381-387

%

3

Standard CPR (with breaths) vs. CC alone

ress

ure

Berg et al, 2001

Blo

od

p

Time

= chest compression

Standard CPR (with breaths) vs. CC alone

ress

ure

Berg et al, 2001

Blo

od

p

Time

= chest compression

1/8/2009

3

Interruptions to Chest Compression during OHCA Resuscitation

• Endotracheal intubation

• Assessing patient (e.g. repeatedly)

• Mouth-to-Mouth ventilation

• Central line placement

• Changing rescuers

• Defibrillation, particularly use of AEDs

Interruptions to Chest Compressions During OHCA

Valenzuela et al. Circulation 2005

Hyperventilation during CPRHyperventilation during CPR

86%

60%

80%

100%

% survival

p= 0.006

13%

0%

20%

40%

12 30

# ventilations per minute

Aufderheide et al. Circulation 2004; 109:1960-5

13 out-of-hospital cardiac arrest patients

Ventilation rate measured during CPR

Average ventilation rate = 37 + 3 per minute (range 15-49)

Hyperventilation during CPRHyperventilation during CPR

Aufderheide et al. Circulation 2004; 109:1960-5

Three-Phase Model of Resuscitation

Three-Phase Model of Resuscitation

CirculatoryElectrical Metabolic

0

100%

Myocardial ATP

0 2 4 6 8 10 12 14 16 18 20

Arrest Time (min)

yPhasePhase Phase

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

40%

50%

60%P=.82

Defibrillation vs. CPR First

(< 5 minute response time)


(< 5 minute response time)

Wik et al. JAMA 2003: 289:1389-95

0%

10%

20%

30%

40%

ROSC D/C Hosp 1yr Surv

CPR first

StandardP=.61 P=.44

40%

50%

60%P=.04


(> 5 minute response time)


(> 5 minute response time)

Wik et al. JAMA 2003: 289:1389-95

0%

10%

20%

30%

40%

ROSC D/C Hosp 1yr Surv

CPR first

StandardP=.006 P=.01

January 19, 2005

Out-of-hospital CPR quality

Wik et al, 2005

1/8/2009

4

Current CPR Quality: Summary

1. Frequent pauses2. Hyperventilation very common3. Defibrillate during Circulatory Phase4.Shallow chest compressions

Cardiocerebral Resuscitation (CCR)

200 chest 200 chest

Single shockwithout pulse Check or rhythmanalysis

lysi

s

200 chest

Single shock if Indicated without pulse check orrhythm analysis

lysi

s


200 chestCCC

EMSarrival

ysis

EMD Instructions CAC

compressions compressions

Passive OxygenInsufflation/15L 02

Begin IV

Ana compressions

Ana

Resume Standard ACLSConsider Endotracheal

Intubation

compressionsOnly•

Administer 1 mg IO/IV Epinephrine

Ana

ly

• If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis

Hypothesis

OHCA victims in Arizona receiving Cardiocerebral ResuscitationCa d oce eb a esusc a o

would have higher survival rates than victims receiving routine Advanced

Life Support

Methods

• Observational analysis from the prospectively collected SHARE database

• IRB approval from the University of Arizona

• 61 EMS agencies in Arizona with varying:• EMS system design• Geography and response intervals• Training schedules• Patient demographics

• Utstein style database• October 2004 to August 2007

Methods: Data Collection and Training

• 11 of 61 (18%) elected to change to CCR

• Train-the-trainer program • January 2005 to April 2007

• ~3,000 EMT (B) and (P) trained

Compliance Criteria for CCR

• Delayed ETI for 3 cycles of 200 CCs and rhythm analysis

• 200 pre-shock chest compressions

• Attempted epinephrine within 10 mins

• 200 post-shock chest compressions

Total cardiac arrestsn= 3,329

171 excluded(age <18 yrs)

Enrollment

598 CCR

3,158 adult 874 excluded – 673 non-cardiac

– 139 EMS witnessed

– 62 missing outcome

2,284 arrests of cardiac etiology

1,686 Routine ALS

ResultsCharacteristics of OHCA Victims

Characteristic CCR (n=598) ALS (n=1,686)

Mean age, years (SD)** 66.1 (15.5) 67.9 (15.0)

Males, % (n) 68.7 (411) 65.1 (1,098)

Home location, % (n)* 76.1 (455) 70.8 (1,194)

SD = Standard deviation *p<0.05 **p<0.01

Bystander CPR performed, % (n) 39.3 (235) 39.3 (663)

Witnessed, % (n) 45.2 (270) 44.1 (744)

Ventricular fibrillation, % (n) 32.6 (195) 30.3 (510)

EMS dispatch to arrival time interval, mean minutes (SD) 5.2 (2.2) 5.6 (3.2)

Witnessed collapse to defibrillation time interval, mean minutes (SD) 13.7 (6.9) 13.3 (7.6)

ResultsSurvival from Out of Hospital Cardiac Arrest

char

ge (

%)

char

ge (

%)

30

25

30

25

(36/128)(36/128)CCRCCR

ALSALS

9.29.2

28.128.1

3.63.6

10.910.9

Sur

viva

l to

Hos

pita

l Dis

cS

urvi

val t

o H

ospi

tal D

isc

20

15

10

5

0

20

15

10

5

0All cardiac arrestsAll cardiac arrests Witnessed with VFWitnessed with VF

(55/598)(55/598)

(61/1686)(61/1686)

(38/348)(38/348)

Bobrow, et al. Circulation. 2007;116:II_923

1/8/2009

5

Discussion: Possible Beneficial Effects of CCR

• Minimize interruptions of marginal forward blood flow during resuscitation efforts

• Minimize hyperventilation during resuscitation

• Delay in advanced airway interventions mayenable providers to focus on compressions and earlier epinephrine administration

Conclusion

Widespread implementation of

Cardiocerebral Resuscitation resulted

in a significant improvement in adult

OHCA survival compared with routine

Advanced Life Support care over the

same time period in Arizona

Arizona EMS

"Statewide Survival From Out-of-Hospital Cardiac Arrest Improves with Widespread

Implementation of Cardiocerebral Resuscitation"

American Heart AssociationBest Resuscitation Abstract

Scientific Sessions 2007

JAMA

• Part I – Before & after comparison of two largest EMS systems in the state

• Part II – Protocol compliance analysis of 10 other EMS systems in the state

Limitations

• Not a RCT

• Possible Hawthorne effect

• Limited electronic waveform data

Cardiocerebral Resuscitation

200 chestcompressions


Single shockwithout pulse Check or rhythmanalysis

Ana

lysi

s



Ana

lysi

s



CCCOnly•

EMSarrival

naly

sis

BVM or PassiveInsufflation 15L NRB

Begin IV

A A

Resume Standard ACLSConsider Endotracheal

Intubation

Administer 1 mg IV/IO Epinephrine

An

Survival by Ventilation MethodN=1,019

tal D

isch

arge

50%

40%

POIBVM

39/102

Odds ratio 2.2 (1.2 – 4.0)

% S

urvi

val t

o H

ospi

t 30%

20%

10%

0%

Non-Shockable Witnessed with VF1.3 %

4/316 3.7 %

14/381

38.2 %

25.8%

Bobrow et al. in press

31/120

Odds ratio 0.3 (0.1-0.9)

1/8/2009

6

Key Questions Remain:

• Perhaps witnessed VF but what about unwitnessed VF, non-shockable rhythms?

• When is active ventilation necessary?

• Should there be two protocols?

• What part of the CCR protocol is most critical?

Before enlightenment, chop wood and carry water

After enlightenment, chop wood and carry water

- Zen saying


SHARE ProgramSHARE ProgramInitiative for Excellence in Initiative for Excellence in

ResuscitationResuscitation




1. Be A Lifesaver (Lay individuals)

2. ACLS Algorithm – Paramedics

3. Post Arrest Care (Pre-arrival & In-hospital)

Bystander CPR > than doubled chance of survival

Bystander CPR only occurred in 25% of arrests

1/8/2009

7

• Hands-Only VideoGasping Following

Out-of-Hospital Witnessed Cardiac Arrest80%

60%

40%

20% 55%20%

10%

0%

55%33%

20%14%

7%

Clark et alAnn Emerg Med1992;21:1464

Bobrow, Zuercher, Ewy et al Circulation 12/9/2008

Dispatch AfterEMS

arrival

EMS< 7 min

EMS7-9 min

EMS>9 min

39%

Dispatch(Witnessed

&Not)






1. Be A Lifesaver (Lay individuals)

2. ACLS Algorithm – Paramedics

3. Post Arrest Care (Pre-arrival & In-hospital)

Therapeutic Hypothermia

http://www.med.upenn.edu/resuscitation/Hypothermia.htm

Aggressive Post Cardiac Arrest Care Saves Lives

viva

l

60%

50%

40%p < 0.05

Surv

30%

20%

10%Before After

34%

59%

Pytte M, Jensen LP, Smedsrud C, Jacobsen D, Mangschau A, Sunde K. Oslo, Norway

Post Cardiac Arrest Team

Cardiology

Rapid Emergency Service

Brain Preservation with Hypothermia

Feedback and System Improvement

Rehabilitation

Critical Care

gy

1/8/2009

8

Cardiac Arrest CentersArizona

21 Cardiac Arrest Centers

Approximately 250 patients/year eligible

`

Bernard SA, et al. Resuscitation 2003; Bernard SA, et al. Resuscitation 2003; 56:956:9--1313

1/8/2009

9

What’s at Stake?

• 5,000 SCA/YR in Arizona• At least 1,000 VF OHCA • 2004 statewide VF survival rate of 7% = 70 lives

2007 statewide VF survival rate of 34% = 340 lives• 2007 statewide VF survival rate of 34% = 340 lives

• At least 270 Lives Per Year!

Future of Cardiac Arrest Research(Translational/Clinical Research)

• Optimized hypothermia - timing, temp, method, duration, rewarming

• Controlled reperfusion

• Neuroprotective pharmacology

• Brain monitoring

• Prognostication of futility

Summary

• High quality CPR and standardized post cardiacarrest care are attainable

• Minimizing interruptions to chest compressions is iti lcritical

• Every community should track their outcomes

• Cardiocerebral Resuscitation is one option to consider to improve outcomes

Thank you

• Our goal is for Arizona to have the highest survival rate in the world for cardiac arrest victims.

www.azshare.gov

Acknowledgement

We are grateful to all the EMS providers in the state of Arizona participating in the SHARE programSHARE program.

This presentation is dedicated to the Firefighters and Paramedics who risk their lives everyday to save others.

mt sinai ccr final.ppt - emcrit project · • ~3,000 emt (b) and (p) trained compliance criteria...

Documents