Future of Cardiac Arrest Management for Paramedics EMS TODAY 2013 Mark Whitbread Consultant Paramedic London Ambulance Service
London Ambulance Service NHS Trust 620 sq miles 8.2 million population 2011/12 1,617.032 999 (911) calls
Specialist Centres 2011/12 95, 270 999 (911) calls for chest pain 8,251 999 (911) calls for cardiac arrest
What outcomes can be achieved? What equipment will be used? What could be done differently?
Adult Cardiac Arrest Checklist (Latest edition: September 2012) On arrival CHECK After ALS initiated CHECK Post ROSC CHECK Effective chest compressions are ongoing and compressors changed regularly? Is the defib in manual mode? Have we got sufficient O 2? Is it attached to BVM and bag inflated? Is the chest rise adequate? If traumatic arrest; has HEMS been considered? Have a 2 nd crew been requested / dispatched? Family supported? Does everyone know each other s names? (If not, introduce self and indicate for others to state name and skill level) Are effective continuous compressions on going? Is the ECG rhythm being assessed every 2 mins? Is there an ETCO 2 waveform present and printed? If value <10mmHg...why? Is there bilateral air entry? Have we checked for tension pneumothorax? Have we got access yet? Is it definitely PATENT? Has fluid been given if hypovolaemia suspected? Have we checked for gastric distension? What is the resp rate? <10 - are we ventilating; 1 breath every 6 seconds? >10 - are sats titrated to 94-98%? Have we got a FULL set of obs? (BP, HR, Sats, BM, 12 lead ECG, ETCO 2 )? What is the BP? If <90, have legs been raised and a 250ml bolus of fluid given? What is the pulse rate? If <60 and symptomatic has atropine 0.5mg been given? Have further fluid boluses been considered if hypovolaemia suspected? ---------TAKE ANOTHER SET OF OBS---------- Is the BP <90? No Do NOT give adrenaline Adrenaline given and amiodarone if required? Has BM been checked? Other reversible causes? Yes Is the pulse rate <100? Yes No Do NOT give adrenaline Are we using an FR2? Has it been swapped for a Lifepak if recurrent VF/VT? Is the radial pulse absent? No Do NOT give adrenaline Has CCD been contacted if up to 18 shocks given (paramedics) Yes Give adrenaline 0.1mg 1:10,000 (note small dose), up to 0.5mg total Completed by: Lead paramedic: Cardiac Arrests are predictable Call sign: CAD: Date: Please see overleaf for leaving scene Checklist Pre planning is essential
Out of hospital 6/65 Multi organ failure 15/65 Cardiovascular 44/65 Neurological In hospital 31/65 Multi organ failure 16/65 Cardiovascular 14/65 Neurological
Issues? It s almost impossible to do RCT s in patients in cardiac arrest It s difficult to increase cardiac arrest survival Guidelines are Guidelines and sometimes we just need to apply common sense JFDI One change will not increase survival
UK Cardiac Arrest Survival (Utstein) DH Ambulance CQI s 2011/12 London 31.7% 24.7% 24% 23.6% 22.6% 20.5% 20.4% 18.7% 18.3% 17.4% 15.1% 10.8%
40% 15%
40% of patients with OHCA are found with VT/VF only 22% achieve ROSC This is a priority group for further efforts to improve ROSC Circ Cardiovasc Qual Outcomes 2010;3:63-81
LAS Non Shockable rhythms ROSC Survival PEA 27.45% 3.31% Asystole 18.23% 0.98%
So
Learn from the real world
Defib download and crew feedback should be the Norm
Quality of ambulance resuscitation No chest compressions 48% of time Number of compressions av. 64/min Depth of compressions av. 3.4cm Wik et al. JAMA 2005; 293: 299-304
Delays are common!
Chest Compressions Pending FDA 510(k) clearance
Arrhythmia Management
Ultrasound in PEA Rapid/Real time/no side effects/accurate/allows critical decision making
Cooling
Issues To increase cardiac arrest survival is difficult It s almost impossible to do RCT s in patient s in cardiac arrest Guidelines are Guidelines! Sometimes we just need to apply common sense JFDI One change in management will not increase survival
Controversial Issues of Cooling Issues To increase cardiac arrest survival is difficult temperature 1. Best cooling method? It s almost impossible to do RCT s in patient s in cardiac arrest Arrest ROSC 1 Guidelines are Guidelines! 3. How deep early 2 Sometimes2. wehow just need to to apply commonto sense JFDI cool? 4 start cooling? One change in management will not increase survival 3 4. How long to time keep cool?
Appropriate management Appropriate destination
ROSC sustained to HAC & Survival
CRM/Checklist Recognise this is serious Close the loop in communication Establish leader Use resources appropriately Step back & do global assessment
Education/Simulation/Training Run simulation See mistakes made Correct mistakes Prevent reoccurrence Find a solution
THANK YOU mark.whitbread@lond-amb.nhs.uk