Conflict of Interest Sarver Heart Center Resuscitation Research Group Cardiocerebral Resuscitation: A New Approach to Cardiac Arrest Bentley J. Bobrow, MD Medical Director Bureau of EMS & Trauma System Arizona Department of Health Services Assistant Professor Department of Emergency Medicine Mayo Clinic College of Medicine Relevant Financial Relationships None Off Label Usage None American Heart Association BLS Guideline Committee Volunteer Objectives Discuss the keys to successful resuscitation Introduce a different approach to OHCA DefineCardiocerebral 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 Kidney Disease Diabetes Alzheimer s NOT YET Cardiac Arrest Major Trauma ST-Elevation MI Acute Stroke YES In the absence of early defibrillation, until very recently OHCA survival rates have not improved 1980 1992 2000 1974 Neurologically norma al survival (%) OHCA Survival 50 40 30 20 16 10 1 2 1? 1/534 0 Chicago 87 Ontario 89 LA 00 Seattle 01 Detroit Arizona 04 02 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 1
Why is OHCA Survival so Low? Poor public knowledge of cardiac arrest Delayed time to first defibrillation Low rates of bystander CPR 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 collaborations to accurately tracking outcomes 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 Program Model for OHCA Collaboration AHA Municipal FDs Public Health Private Ambulance Local Hospitals Private Industry University Researchers Public 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 73 SHARE Participants Apache Junction FD Kingman FD River Medical Ambulance Arivaca FD Lake Mohave Ranchos FD Rural Metro Avondale FD Lifeline Ambulance Scottsdale FD Blue Ridge FD Lifestar Ambulance Sedona FD Buckeye Valley FD Maricopa FD Seligman FD Chandler FD Mayer FD Sonoita - Elgin FD Central Yavapai FD Mesa FD Southwest Ambulance Chino Valley FD Montezuma/Rim Rock FD Summit FD Daisy Mountain FD Nogales FD Sun City FD Elephant Head Volunteer FD Nogales Suburban FD Sun City West FD El Mirage FD Northwest FD Sun Lakes FD Flagstaff FD Page FD Surprise FD Patagonia Lake State Park/Sonoita Creek Gila River Indian Community EMS State Natural Area FD Tempe FD Gilbert FD Patagonia Volunteer FD Tolleson FD Glendale FD Payson FD Tonopah Valley FD Golden Valley FD Peach Springs EMS Tubac FD Goodyear FD Peoria FD Tucson FD United States Border Patrol Grapevine Mesa FD Phoenix FD -AZ Green Valley FD Pine Lake FD Tusayan FD Guadalupe FD Pinewood FD Verde Valley FD Guardian Medical Transport Pinion Pine FD Walker FD Helmet Peak FD PMT Western Air Rescue Hualapai Valley FD Prescott FD Yarnell Fire District Puerco Valley FD Yuma FD 6/24/2008 OHCA Survival in Arizona Standard CPR (with breaths) vs. CC alone Standard CPR (with breaths) vs. CC alone % 50 40 30 20 10 0 3 Arizona 2004 With so few survivors, we felt compelled to make modifications to protocol based upon current evidence and track the results closely. ressure Blood p Time = chest compression Berg et al, 2001 ressure Blood p Time = chest compression Berg et al, 2001 Bobrow et al, Prehospital Emergency Care 2008;12:381-387 2
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 CPR 10 8 % survival 6 86% p= 0.006 12 30 # ventilations per minute 13% Aufderheide et al. Circulation 2004; 109:1960-5 Hyperventilation during CPR 13 out-of-hospital cardiac arrest patients Ventilation rate measured during CPR Average ventilation rate = 37 + 3 per minute (range 15-49) 10 Three-Phase Model of Resuscitation Myocardial ATP 0 Electrical Circulatory Metabolic Phase Phase Phase Defibrillation vs. CPR First (< 5 minute response time) P=.82 6 5 3 P=.61 P=.44 CPR first Standard 1 0 2 4 6 8 10 12 14 16 18 20 Arrest Time (min) ROSC D/C Hosp 1yr Surv Aufderheide et al. Circulation 2004; 109:1960-5 Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8 Wik et al. JAMA 2003: 289:1389-95 Defibrillation vs. CPR First (> 5 minute response time) January 19, 2005 Out-of-hospital CPR quality 6 P=.04 5 3 P=.006 P=.01 CPR first Standard 1 ROSC D/C Hosp 1yr Surv Wik et al. JAMA 2003: 289:1389-95 Wik et al, 2005 3
Current CPR Quality: Summary 1. Frequent pauses 2. Hyperventilation very common 3. Defibrillate during Circulatory Phase 4.Shallow chest Cardiocerebral Resuscitation (CCR) EMD Instructions CCC Only EMS arrival Analy ysis Single shock without pulse Check or rhythm analysis Passive Oxygen Insufflation/15L 0 2 Begin IV Ana lysis Administer 1 mg IO/IV Epinephrine Single shock if Indicated without pulse check or Ana lysis Single shock if Indicated without pulse check or CAC Resume Standard ACLS Consider Endotracheal Intubation If adequate bystander chest are provided, EMS providers perform immediate Hypothesis OHCA victims in Arizona receiving Cardiocerebral eb a Resuscitation 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 Methods: Data Collection and Training Utstein style database October 2004 to August 2007 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 200 pre-shock chest Attempted epinephrine within 10 mins 200 post-shock chest Enrollment Results Characteristics of OHCA Victims Results Survival from Out of Hospital Cardiac Arrest Total cardiac arrests n= 3,329 171 excluded (age <18 yrs) 3,158 adult 874 excluded 673 non-cardiac 139 EMS witnessed 62 missing outcome 2,284 arrests of cardiac etiology 1,686 Routine ALS 598 CCR 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) 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) Standard deviation *p<0.05 **p<0.01 SD = charge (%) Survival to Hospital Disc 30 25 20 15 10 5 0 CCR ALS (61/1686) (55/598) 9.2 3.6 All cardiac arrests (38/348) 10.9 (36/128) 28.1 Witnessed with VF Bobrow, et al. Circulation. 2007;116:II_923 4
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 may enable providers to focus on 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 Association Best 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 Cardiocerebral Resuscitation Survival by Ventilation Method N=1,019 Not a RCT Possible Hawthorne effect Limited electronic waveform data CCC Only EMS arrival An nalysis BVM or Passive Insufflation 15L NRB Begin IV Single shock without pulse Check or rhythm analysis Analysis Administer 1 mg IV/IO Epinephrine Single shock if Indicated without pulse check or Analysis Single shock if Indicated without pulse check or Resume Standard ACLS Consider Endotracheal Intubation tal Discharge % Survival to Hospit 5 3 1 POI BVM Odds ratio 0.3 (0.1-0.9) 4/316 1.3 % 14/381 3.7 % Non-Shockable Odds ratio 2.2 (1.2 4.0) 39/102 31/120 38.2 % 25.8% Witnessed with VF Bobrow et al. in press 5
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 Program Initiative for Excellence in Resuscitation Bystander CPR > than doubled chance of survival Bystander CPR only occurred in 25% of arrests Cardiocerebral Resuscitation 1. Be A Lifesaver (Lay individuals) 2. ACLS Algorithm Paramedics 3. Post Arrest Care (Pre-arrival & In-hospital) 6
Hands-Only Video 8 6 Gasping Following Out-of-Hospital Witnessed Cardiac Arrest 55% 39% 33% 1 14% 7% Dispatch Dispatch After EMS EMS EMS (Witnessed EMS < 7 7-9 >9 & arrival min min min Not) Clark et al Ann Emerg Med Bobrow, Zuercher, Ewy et al Circulation 12/9/2008 1992;21:1464 SHARE Program Initiative for Excellence in Resuscitation Cardiocerebral Resuscitation 1. Be A Lifesaver (Lay individuals) 2. ACLS Algorithm Paramedics 3. Post Arrest Care (Pre-arrival & In-hospital) http://www.med.upenn.edu/resuscitation/hypothermia.htm Therapeutic Hypothermia vival Surv Aggressive Post Cardiac Arrest Care Saves Lives 6 5 3 1 p < 0.05 34% Before 59% After Pytte M, Jensen LP, Smedsrud C, Jacobsen D, Mangschau A, Sunde K. Oslo, Norway Post Cardiac Arrest Team Cardiology Rapid Brain Preservation Feedback and Rehabilitation Emergency Service with Hypothermia System Improvement Critical Care 7
Cardiac Arrest Centers Arizona 21 Cardiac Arrest Centers Approximately 250 patients/year eligible ` Bernard SA, et al. Resuscitation 2003; 56:9-13 8
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 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 cardiac arrest care are attainable Minimizing interruptions to chest is critical 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 program. This presentation is dedicated to the Firefighters and Paramedics who risk their lives everyday to save others. 9