GETTING TO THE HEART OF THE MATTER Ritu Sahni, MD, MPH Lake Oswego Fire Department Washington County EMS Clackamas County EMS
TAKE HOME POINTS CPR is the most important thing Train like we fight Measure and Improve Life is about expectation management
WHAT S THE BIG DEAL? Improving survival from cardiac arrest is happening! Why? A ton of new information over last 8 years.
RESUSCITATION OUTCOMES CONSORTIUM (ROC) Large-scale, government-supported, North American effort to conduct prehospital cardiac arrest and severe traumatic injury randomized clinical trials Focus: very early delivery of EMS interventions Optimal potential for benefit for treating cellular injury
US AND CANADA FUNDING PARTNERS National Heart, Lung & Blood Institute National Institute for Neurologic Diseases and Stroke American Heart Association Canadian Institutes of Health Research Defense Research and Development Canada Heart and Stroke Foundation of Canada US Department of Defense
TOTAL INVESTMENT (2005-15) US $114 MILLION AHA $5M DOD $13.5M Canada $6.5M 2004-2009 2010-2015 NIH-NINDS $5M NIH-NHLBI $84M
ROC STUDY SITES MASSIVE INFRASTRUCTURE 10 primary, 8 satellite sites 1 primary DCC, 1 satellite DCC, 1 satellite CCC > 264 EMS and fire agencies 80% Fire Vancouver > 35,000 square miles > 24 million people Seattle-King Co Data Coordinating Center, Seattle Portland Milwaukee Ottawa Toronto Pittsburgh > 3,600 EMS vehicles Orange County San Diego Memphis Alabama > 36,000 EMS personnel Dallas > 100 IRB s > 287 hospitals Davis DP, et al. Prehosp Emerg Care 2007; 11:369-82
ROC WHAT DID WE LEARN?
SUMMARY OF ROC STUDIES Name Study Type Dates Sample Size Epidemiologic Registry-Cardiac Registry 2005-2015 >127,000 Epidemiologic Registry-Trauma Registry 2005-2007 13,700 Hypertonic Saline in Traumatic Shock RCT 2006-2008 895 Hypertonic Saline in Traumatic Brain Injury RCT 2006-2009 1331 Analyze Early vs Analyze Later in Cardiac Arrest* RCT 2007-2009 15,000 Impedance Threshold Device in Cardiac Arrest* RCT 2007-2009 9,000 CPR Feedback in Cardiac Arrest RCT 2006-2008 1819 Prospective Observational Prehospital and Hospital Registry for Trauma Registry 2010-2011 7,319 Resuscitative Endocrinology: Single-dose Clinical Uses for Estrogen in Traumatic Shock Pilot Study Resuscitative Endocrinology: Single-dose Clinical Uses for Estrogen in Traumatic Brain Injury Pilot Study RCT 2010-2012 50 RCT 2010-2012 50 Hypotensive Resuscitation in Traumatic Shock Pilot Study RCT 2012-2013 192 Continuous Cardiac Compressions vs Standard CPR in Cardiac Arrest* RCT 2011-2015 23,710 Amiodarone vs Lidocaine vs Placebo Study in Cardiac Arrest* RCT 2012-2015 3,025 Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) RCT 2012-2013 680 TXA (Tranexamic Acid in TBI) RCT 2015-present 1002 PROHS (Prehospital Resuscitation on Helicopter Study) Observationa l 2014-2015 7000 ROC Pragmatic Airway Resuscitation Trial (PART) RCT 2015-present 3000
SCIENTIFIC IMPACT OF ROC STUDIES > 60 peer reviewed publications > 70 abstracts > 1,500 citations Major impact on AHA/ILCOR 2010 and 2015 Resuscitation Guidelines Multiple other publications and grants Training core graduates EMS providers as authors
CARDIAC ARREST: ANALYZE EARLY VS. ANALYZE LATER Compressor Other Provider(s) Compressor Other Provider(s) 30-60 sec 50+ compressions Apply AED and turn on Apply ITD 30-60 sec Apply AED and turn on Apply ITD Analyze/shock 300 compressions ACLS 3 min Analyze/shock ACLS Analyze Early Analyze Later Prime the Pump Increase Chances of Restarting Heart
CARDIAC ARREST: IMPEDANCE THRESHOLD DEVICE (ITD) No flow Recoil Induce Vacuum in Chest Increase Coronary Blood Flow
Factorial Design Impedance Threshold Device (ITD vs. Sham) Duration of CPR Before Rhythm Analysis (AE vs. AL) ROC PRIMED Planned 10,000 patient enrollment Interim analysis Futility for both ITD and AE/AL
CPR FEEDBACK STUDY Difference = -0.4% (-5.2%, 4.4%) ROSC Difference = -1.9% (-4.3%, 0.4%) Survival
ROC - CCC Cluster Randomization 2 CPR strategies before advanced airway placement Early use of epinephrine Continuous Compressions with ventilation every 10 (CCC) vs. 30:2 (ICC) Enrolled 23,711 Survival to discharge 9.0% (CCC) 9.7% (ICC) p value 0.07
AMIODARONE-LIDOCAINE-PLACEBO STUDY (ALPS) RCT, adult OHCA Shock refractory initial VF/VT Interventions: Amiodarone (450 mg) Lidocaine (180 mg) Placebo N=3,025 subjects NO DIFFERENCE (p=0.08) Witnessed arrest DIFFERENCE!
SO WHAT S THE BIG DEAL? Roc EPISTRY!
ROC EPISTRY HIGHLIGHTS Epidemiological Registry = Epistry Data collection began December 1, 2005. Collected All cardiac arrests, DOS CPR process data
IMPORTANCE OF PUBLIC ACCESS DEFIBRILLATION Higher Survival with Bystander AED Shock % Survival to Hospital Discharge 40 35 30 N= 149 N= 300 25 20 N= 259 15 N= 1293 10 5 N= 10663 N= 3191 0 ALL Patients EMS Care Bystander CPR, no Bystander AED Bystander AED Placed Bystander AED Shock Bystander CPR EMS Shocked EMS Witnessed EMS Shocked
Secondary ROC Analysis IMPACT OF CHEST COMPRESSION Higher CCF FRACTION Higher Survival ON SURVIVAL? N=506 VF/VT arrests CCF = portion of each minute with active chest compressions Adjusted OR 5 4 3 2 1 0 1 Primary Analysis Adjusted OR of Survival n=97 n=73 n=115 n=132 n=67 95% CI 0.87. 5.22 1.00, 5.08 1.20. 6.88 1.50, 7.26 2.13 2.26 2.88 3.3 0-20 21-40 41-60 61-80 81-100 Chest Compression Fraction *Adjusted for: age, gender, public location, time from 911 call to arrive at scene, bystander CPR, chest compression rate Christenson, et al., Circulation 2009
CHEST COMPRESSION RATE 100- Cubic Spline of Survival vs Chest Compression Rate 95% confidence intervals as dashed lines 120 Probability of Survival to Discharge 0.05.1 50 75 100 125 150 175 200 Average Chest Compression Rate Indris et al. 2015;43:840-8
Ian G. Stiell et al. Circulation. 2014;130:1962-1970 CHEST COMPRESSION DEPTH
PRE-, POST- AND PERI-SHOCK PAUSE
Pre-, Post- and Peri-shock Pause Pre-Shock (secs) Post-Shock (secs) Peri-Shock (secs) Median Pre and Post Shock Pause Unadjusted OR 95% CI Adjusted OR 95% CI >20 Reference -- Reference -- 10-19.9 1.34 (1.09, 1.66) 1.25 (0.95, 1.65) <10 1.73 (1.36, 2.19) 1.52 (1.09, 2.11) >10 Reference -- Reference -- 5-9.9 1.09 (0.86, 1.37) 1.02 (0.75, 1.38) <5 2.01 (1.58, 2.55) 1.34 (0.94, 1.90) >40 Reference -- Reference -- 20-39.9 1.22 (0.88, 1.71) 1.16 (0.76, 1.76) <20 2.17 (1.56, 3.02) 1.82 (1.17, 2.85)
COMPRESSIONS MATTER!!! Quality Time to first compression Chest compression fraction Pauses WHAT DOES THIS MEAN?
HOW DO WE FIX THAT? Train like we fight Create known expectations (Life is about expectation management) Measure and improve Medications are important just don t know which ones yet and are likely useless in the face of bad CPR
Notice all the medica TRAIN LIKE WE FIGHT