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Strategies
to Improve
Survival
from
Sudden Cardiac Arrest:
An Evidence-Based Analysis
March 2014
Executive Summary
This document, written by faculty of the Resuscitation Academy and staff of King County Emergency
Medical Services, provides 35 strategies to improve survival from sudden cardiac arrest. We classify the
individual strategies under 6 categories of CPR, defibrillation, advanced life support, post-resuscitative
care, EMS system, and future approaches. Admittedly our selection of the 35 strategies is somewhat
arbitrary but we have tried to be comprehensive. Our approach is focused on the pre-hospital
management of sudden cardiac arrest and specifically ventricular fibrillation associated cardiac arrest.
Though many of these strategies apply to cardiac arrests in hospitals we have chosen to stick to the world
we know best.
In the Resuscitation Academy we categorize strategies into low hanging and high hanging fruit. We think
of all the 35 strategies listed in this document, the lowest-hanging fruits (meaning relatively easy to
implement and having the highest likelihood to improve cardiac arrest survival) are high-performance
CPR and telecommunicator-CPR. These two strategies will not be effective without ongoing quality
improvement programs and QI programs are not possible without a cardiac arrest registry. Our emphasis
on the low hanging fruit should not discount the other strategies - many of which will have positive
impacts. Perhaps the most important strategy may be the most difficult to achieve - creating a culture of
excellence. Though hard to quantify, its impact is immense. Leadership, determination, uncompromising
standards - the stuff of excellence - is a strategy that subsumes all the others.
Contributors
David Carlbom, MD
Ann Doll, BA
Mickey Eisenberg, MD
Jamie Emert, MPH
Sofia Husain, MPH
Peter Kudenchuk, MD
Tom Rea, MD
Michael Sayre, MD
Larry Sherman, MD
Ben Stubbs, MPH
2
Contents
Strategies.......................................................1
Executive Summary........................................2
A Profile of Out-of-Hospital Cardiac Arrest.....5
5. EMS System..............................................59
1. CPR..........................................................15
1. Cardiac arrest registry.....................................................59
1. Train the general population in CPR/AED...........................15
2. Cardiac arrest as a reportable condition.............................60
2. Use the web and apps to teach CPR.................................19
3. Quality improvement (QI) for cardiac arrest.......................62
3. Telecommunicator CPR....................................................21
4. QI for T-CPR..................................................................63
4. Improve the quality of CPR through high-performance CPR..24
5. Create a culture of excellence..........................................66
5. Mandate CPR/AED training in schools...............................27
6. Establish a medical model................................................67
6. Automatic CPR devices...................................................29
7. Telecommunicator rapid dispatch.....................................31
6. Future Approaches....................................71
1. Develop defibrillators that detect rhythm during CPR...........71
2. Defibrillation.............................................33
2. Develop defibrillators to guide therapy...............................74
1. Increase Public Access Defibrillator (PAD) programs............33
3. Develop an inexpensive “consumer” defibrillator.................76
2. Train and equip police with AEDs......................................35
4. Change FDA classification of public defibrillators.................78
3. Change building codes to require PADs..............................38
5. Hemofiltration for post-resuscitation therapy......................80
4. Register AEDs and notify volunteers of cardiac arrests and location of AEDs............................................................39
6. ECMO for cardiac arrest...................................................81
7. Detect blood flow during cardiac arrest..............................82
3. Advanced Life Support..............................42
8. Ischemic post-conditioning therapy...................................85
1. Advanced airway management........................................42
9. Point of care testing........................................................87
2. Medications...................................................................45
10. Develop a cardiac arrest detector....................................89
3. Ratio of paramedics to population and optimal number of EMS responders....................................................................47
11. Prevent the onset of ventricular fibrillation.......................90
Summary.....................................................92
4. Post-resuscitative Care:...........................50
Appendix......................................................93
1. Hypothermia.................................................................50
2. Care mapping...............................................................52
3. Resuscitation centers......................................................54
4. Percutaneous coronary intervention (PCI)..........................56
3
Introduction
Much has been written about how to improve the generally low survival rates from sudden cardiac arrest
(SCA) with many strategies offered. This document provides a comprehensive listing of the strategies as
well as an evidence-based analysis of each strategy.
The focus is primarily on out-of-hospital ventricular fibrillation since it is the most “resuscitatable” type
of cardiac arrest. 35 strategies are considered. Though we do not specifically discuss in-hospital cardiac
arrest, many of the strategies are equally applicable in the hospital setting.
Surviving SCA requires an optimal confluence of patient, event, system, and therapy factors. For example
the patient factor of co-morbidity is a strongly associated with survival. Similarly the event factors of
witnessed collapse and the rhythm associated with the event are critical. Key therapy interventions
and the time to provide them (such as the intervals from collapse to the start of CPR and provision of
defibrillation) as well as system factors are extremely important as well. This analysis pays little attention
to factors of fate (patient and event factors) and instead focuses almost exclusively on therapy and
system factors.
4
A Profile of Out-of-Hospital Cardiac Arrest
Sudden cardiac arrest (SCA) is the leading cause
the key patient, incident and system factors that
of death among adults in the United States.
should be considered when discussing sudden
Though the causes of SCA are many, the leading
cardiac arrest. While the data presented are
cause is underlying coronary artery disease. The
specific to King County, similar results have been
cardiac rhythms associated with SCA are asystole
reported elsewhere.
(flat line), pulseless electrical activity (PEA) and
Who is Affected by Sudden Cardiac
Arrest?
ventricular fibrillation (VF). Of these rhythms VF
is the most treatable with a reasonable chance of
The incidence of EMS-treated sudden cardiac
survival. Among patients with witnessed collapse
arrest has been estimated to be approximately 55
(meaning the collapse of the person was seen or
per 100,000 population, with survival to hospital
heard) VF is present 40% of the time. In a few
discharge approximately 8%. The incidence of
communities, survival (discharged alive from
arrest with ventricular fibrillation as the initial
the hospital) from witnessed VF exceeds 50%.
rhythm is estimated to be between 13 and 21 per
Regrettably in most communities survival rates
100,000 population, with survival of approximately
from VF arrest are in the single digits or teens.
20%. In children and young adults, the incidence
of cardiac arrest due to cardiac causes is
The following profile presents data on EMS-treated
approximately 2 per 100,000 population, with
cardiac arrests in King County, Washington,
overall survival close to 25%.
population 1.4 million (excluding the city of
Seattle). The purpose of the profile is to highlight
Age Group
Sex
Number (%) with
Mean Age
SCA
Adults 18 and older Male
Children less than
p-value for
difference in age
4226 (64%)
63.2
Female
2414 (36%)
66.6
Male
142 (56%)
5.2
Female
114 (44%)
4
<0.001
0.003
18
Table 1. Number of patients with SCA and mean age by age group in King County, WA, 2005 -2012.
5
In adults, sudden cardiac arrest occurs mostly in
whether trauma was the outcome of the cardiac
men who are, on average, younger than women
arrest or its cause). There are many causes of
who suffer a SCA. Several studies have shown that
SCA, which may vary based on the age of the
symptoms and presenting characteristics, such as
patient (see Figure 1). Causes (also referred
initial rhythm, are different in women compared
to as etiology) are often classified as cardiac
to men. In children, the trend in age is reversed.
(coronary artery disease, dysrhythmias, structural
For example, Table 1 on the previous page shows
and electrical problems with the heart) or non-
that in patients 18 and older, 64% of arrests are
cardiac (respiratory causes, complications of non-
in men, who are approximately 3.5 years younger
cardiac comorbidities, trauma, overdose). Causes
than women. In children and adolescents, 56%
are often determined based on EMS provider
of arrests are in boys, who are, on average, 1
impressions, but may also be classified based
year older than girls. This is most likely due to the
on review of hospital and death records. In the
higher rate of sports-related arrests in boys in their
absence of an obvious noncardiac cause, a cardiac
teens.
arrest is usually presumed to be of a cardiac
etiology. Most reports are limited to subjects with
By definition, SCA excludes traumatic etiologies
a cardiac etiology, as this is considered the most
(although it is sometimes difficult to distinguish
homogeneous subject population.
100%
87%
Cardiac
Non-Cardiac
80%
71%
70%
60%
60%
40%
40%
30%
29%
20%
13%
0%
0 - 17
18 - 39
40 - 64
65+
Age
Figure 1: Percent of sudden cardiac arrest patients with cardiac or non-cardiac causes (excluding trauma)
by age group, King County, WA, 2005-2012 (N=6451)
6
initiate a quick response. EMS-treated arrests may
Factors That Influence the Chance
of Survival
also occur in medical clinics or care facilities such
as nursing homes, adult family homes or assisted
Most instances of sudden cardiac arrest occur in
living facilities. These patients tend to survive
the home. Patients who arrest in a public location
at lower rates because they often have multiple
have a better chance of surviving to hospital
serious medical conditions that reduce the chances
discharge because, in most cases, someone is
of a successful resuscitation. See Figure 2 for an
more likely to see a person collapse in public and
example from King County data.
Figure 2: Number of EMS-Treated Cardiac Arrests and
Percent Surviving to Hospital Discharge for Each Location
Type, King County, WA, 2005-2012 (N=6864). Percentages
represent the proportion of patients having a cardiac arrest
in each location who survived to hospital discharge.
5000
Died
Survived
Number of Events
4000
3000
2000
1000
0
15%
8%
32%
Home
Public
7
Clinic, care facility
The likelihood of survival decreases with each
interval is the time from EMS activation to the
minute that a patient goes without CPR or
initiation of CPR (whether by a bystander or by
defibrillation. Therefore, the time it takes for
EMS personnel) and the time to first defibrillation,
EMS personnel to arrive and treat the patient is
if applicable. However, EMS incident reports may
an important factor that influences the chance
not provide accurate CPR and defibrillation times.
of survival. Ideally, this time interval would be
Emergency dispatch center audio recordings and/
measured from the time of collapse. But this
or defibrillator data may be queried to obtain these
time is very difficult to measure, so a common
data, which may lead to more accurate times. But
substitute is the time that the EMS response was
collecting data from these sources is difficult and
activated (usually by a call to the emergency
may lead to a high rate of missing times.
response number). A more clinically relevant time
See Table 2 below.
Time from Emergency
Median (25%,
Percent
call to:
75%)
Missing
First EMS unit arrival
5:23 (4:24, 6:46)
1%
Source of data
Computer aided
dispatch report
CPR by a bystander
2:29 (1:50, 3:26)
47%
Emergency call
audio recording
CPR by EMS when
8:24 (6:38, 10:58)
49%
bystander CPR not
EMS defibrillator
data
given (includes EMSwitnessed arrests)
First shock
11:36 (7:57,
21%
20:01)
EMS or public access
defibrillator data
Table 2 Time from Emergency Call to Key Endpoints, King County, WA Sept. 1, 2012 - Sept. 31, 2013.
8
50.0%
49%
Witnessed
Unwitnessed
45.0%
40.0%
35.0%
30.0%
25.0%
20%
20.0%
16%
15.0%
10%
8%
10.0%
5.0%
1%
0.0%
VF
PEA
Asystole
VF
PEA
Asystole
Figure 1: Initial Cardiac Arrest Rhythm by Witnessed Status, King County Washington, 2005 - 2012
Figure 3: Survival to Hospital Discharge by Initial Cardiac Arrest Rhythm
And Witnessed Status, King County, WA, 2005-2012 (N=6720)
When a SCA is seen or heard, the chances of
these rhythms can sometimes resolve to a normal
survival increase. If an arrest is witnessed, it is
rhythm with high quality CPR and administration
likely that the patient receives treatment relatively
of drugs. The graph above depicts the survival
quickly, so witnessed status becomes an indicator
from witnessed and unwitnessed cardiac arrest
of the “freshness” of the event.
by the presenting arrhythmia. Witnessed VF has
the highest likelihood of survival though even
The initially measured heart rhythm is another
unwitnessed VF has a decent chance of survival.
important factor. Patients with ventricular
PEA has a worse chance of survival and the worst
fibrillation (VF) or pulseless ventricular tachycardia
chance of survival is found for asystole.
(VT) can be shocked into a normal rhythm with
a defibrillator (these are often referred to as
When the patient population is limited to subjects
“shockable” rhythms). A defibrillator shock cannot
with a suspected cardiac cause of arrest, the
restore a normal rhythm for patients with pulseless
proportion of cases with VF as an initial rhythm
electrical activity (PEA) or asystole (these are often
is declining (see Figure 4). This is likely due to
referred to as “unshockable” rhythms). However,
improved primary and secondary prevention
9
Annual Incidence Rate per 1000 Population
1
VF
0.85
PEA
0.8
Asystole
0.6
0.54
0.38
0.4
0.31
0.31
0.23
0.25
0.25
1979-1980
1989-1990
1999-2000
0.28
0.2
0
Figure 4: Age- and Sex-Adjusted Incidence Rates of Out-Of-Hospital Cardiac Arrest Treated by the
Seattle Fire Department, 1979-2000. Adapted from Cobb LA, et. al. Changing incidence of out-ofhospital ventricular fibrillation, 1980-2000. JAMA. 2002;288:3008-13.
efforts targeting coronary artery disease. It
How is Sudden Cardiac Arrest Treated?
does suggest, however, that successful therapies
The two most critical interventions for
focusing on patients with an initially unshockable
ventricular fibrillation cardiac arrest are rapid
cardiac rhythm must be developed in order for
cardiopulmonary resuscitation (CPR) and rapid
improvement in overall survival to continue.
provision of defibrillation. When the heart stops
pumping blood during a SCA, effective CPR will
circulate oxygenated blood to the body and
brain. If someone gives CPR before EMS arrives
(referred to as bystander CPR), this reduces
the time that the patient is without circulation.
Community CPR training programs may increase
the rate of bystander CPR. Telecommunicator-CPR
programs, in which emergency dispatcher provide
10
CPR instructions, have been shown to increase
In other words CPR “slows the dying process” and
bystander CPR rates and survival. It is widely
gives extra time for a defibrillatory shock to be
reported that bystander CPR doubles or triples
delivered and still be successful.
the odds of survival compared to no bystander
CPR. Recent data in the past 5 years shows that
Other aspects of care include medicaltions and
the quality of CPR also improves the chance of
airway control. Paramedics often protect the airway
survival. The term widely used for high quality CPR
and administer drugs. Hospitals continue patient
is high-performance CPR (HP-CPR). For ventricular
care and may initiate hypothermia or provide
fibrillation cardiac arrest public access defibrillators
percutaneous coronary intervention (PCI) when
offer the possibility of achieving rapid defibrillation
appropriate. In some communities paramedics
prior to EMS arrival.
begin hypothermia therapy prior to hospital arrival.
There is an interaction between CPR and
How are Patient Outcomes Measured?
defibrillation. When both are provided quickly
there is an excellent chance of survival. The two
interventions interact and work in parallel. Both are
required quickly but if CPR can be started quickly
there can be a small delay in providing defibrillation
and still achieve decent survival rates. A simplified
way to express this interaction is that survival from
witnessed VF arrest declines by about 7% - 10%
for every minute that CPR and defibrillation are
delayed. When CPR is begun quickly (particularly
if it is HP-CPR) the rate in the fall of survival with
delay to defibrillation is lessened.
Most studies report survival to hospital discharge.
If resources allow, neurologic status at hospital
discharge (as measured by CPC or modified Rankin
Score) should also be reported. Additional patient
outcomes that may be reported include: a return
of spontaneous circulation (ROSC), survival to
hospital arrival, 30-day mortality and 1-year (or
greater) mortality.
Most communities in the US have poor survival
rates. (See Figure 5, page 12) For VF the rates
range from zero to 50% and recent data from
Seattle and King County report a survival rate
11
Figure 5: Survival To Hospital Discharge For Out-of-Hospital Cardiac Arrest with VF as the Initial Rhythm For Various Communities. From Eisenberg, MS. Resuscitate! How Your Community Can Improve Survival From Sudden Cardiac Arrests. 2nd
ed. Seattle, University of Washington Press, 2013, P. 7.
of 57%. The CARES registry (representing
compared to witnessed collapse
approximately 25% of the US population) reports
witnessed VF survival of almost 30%.
•
There are variable survival rates throughout the
country
Summary facts:
•
Of the three rhythms causing cardiac arrest VF
•
minute of delay in CPR and defibrillation
has a reasonable chance of resuscitation
•
Unwitnessed collapse fares much worse
Likelihood of survival falls 7-10% for every
•
12
CPR doubles - triples the likelihood of survival
How are Cardiac Arrest Data Reported?
from the hospital (1087/3434 = 31.7%). The
The Utstein guidelines provide recommendations
“Neurological Status” box show that 952/ 1087
on the reporting of cardiac arrest data. These
patients (87.6%) had a favorable neurological
guidelines highlight the patient, treatment and
status at hospital discharge. CARES also provides
system factors that should be reported and, if
similar reports focusing on unwitnessed events and
used correctly, allow comparison between different
events witnessed by EMS providers.
systems.
The indicator most often used is survival to hospital
discharge for witnessed arrests of cardiac etiology
with VF or pulseless VT as an initial rhythm. There
are two reasons for this: 1) These are the patients
with the greatest possibility of survival, and 2) this
defines a patient population that is similar from one
study to the next and allows comparison over time
or between systems.
The following paragraph refers to the “Utstein
Survival Report” found in the Appendix.
“Resuscitations Attempted” should include all
incidents treated by EMS that have a confirmed
loss of pulse and blood pressure, that receive CPR
by EMS personnel or that receive a defibrillatory
shock (either by a by EMS or by a public access
defibrillator). The denominator for reporting survival
is found in the “Initial Rhythm VF/VT” box (3434)
and represents the number of bystander witnessed
incidents of cardiac etiology with an initial rhythm
of VF or pulseless VT. Following the arrows directly
down from this box to the “Discharged Alive” box
gives the number of patients discharged alive
Approach
The treatment of cardiac arrest is complicated and
challenging. The multiple strategies are divided
into 6 categories. The categories are distinct but
not precisely demarcated. For example, teaching
CPR to the general public also entails teaching
about automated external defibrillators (AEDs). The
first four categories (CPR, defibrillation, advanced
life support, and post-resuscitative care) follow
the sequence in treating a cardiac arrest. The 5th
category deals with the EMS system as a whole
and the 6th category features future approaches.
Each strategy has a brief description followed by a
summary of the scientific evidence in support of the
strategy (as well as relevant articles) and an overall
assessment. In addition there is an appraisal of the
strategy’s impact (its potential to improve survival)
and its ease or difficulty of implementation.
The categories and the strategies
Following are the 6 categories (CPR, Defibrillation,
Advance life support, Post-resuscitative care, EMS
system, and Future approaches) and the 35 specific
strategies:
13
The Categories and Strategies
1. CPR..........................................................15
5. EMS System..............................................59
1. Train the general population in CPR/AED...........................15
1. Cardiac arrest registry.....................................................59
2. Use the web and apps to teach CPR.................................19
2. Cardiac arrest as a reportable condition.............................60
3. Telecommunicator CPR...................................................21
3. Quality improvement (QI) for cardiac arrest.......................62
4. Improve the quality of CPR through high-performance CPR..24
4. QI for T-CPR..................................................................63
5. Mandate CPR/AED training in schools...............................27
5. Create a culture of excellence..........................................66
6. Automatic CPR devices...................................................29
6. Establish a medical model...............................................67
7. Telecommunicator rapid dispatch......................................31
6. Future Approaches....................................71
2. Defibrillation.............................................33
1. Develop defibrillators that can accurately detect the underlying cardiac rhythm while CPR is being performed.....71
1. Increase Public Access Defibrillator (PAD) programs............33
2. Develop defibrillators to intelligently guide therapy.............74
2. Train and equip police with AEDs......................................35
3. Develop an inexpensive “consumer” defibrillator.................76
3. Change building codes to require PADs.............................38
4. Change FDA classification of public defibrillators.................78
4. Register AEDs and notify volunteers of cardiac arrests and location of AEDs............................................................39
5. Hemofiltration for post-resuscitation therapy......................80
6. ECMO for cardiac arrest...................................................81
3. Advanced Life Support..............................42
7. Detect blood flow during cardiac arrest.............................82
1. Advanced airway management........................................42
8. Ischemic post-conditioning therapy...................................85
2. Medications...................................................................45
9. Point of care testing........................................................87
3. Ratio of paramedics to population and optimal number of EMS responders....................................................................47
10. Develop a cardiac arrest detector....................................89
11. Prevent the onset of ventricularfibrillation.......................90
4. Post-resuscitative Care............................50
1. Hypothermia..................................................................50
2. Care mapping...............................................................52
3. Resuscitation centers......................................................54
4. Percutaneous coronary intervention (PCI)..........................56
14
1. CPR
Strategies in this category relate to providing CPR
compression only by nonprofessional providers
as quickly as possible and performing high quality
for adult cardiac arrest. As evidence of CPR is
CPR.
required for many employment situations the AHA
and ARC have issued certification or completion
1. Train the general population in
CPR/AED
Description:
The technique of closed chest CPR was first
reported in 1960 and the skill spread outward from
the hospital to involve the general public. In 1973
Dr. Leonard Cobb began a program in Seattle, WA
to train the general public in CPR. The goal was to
train 100,00 people in a three hour course. Today
approximately 75% of the Seattle/King County
population has been trained in CPR. Numerous
studies demonstrate benefit with bystander
CPR with doubling and even tripling of survival.
National organizations such as the American Heart
Association (AHA) and the American Red Cross
(ARC) promote CPR training of the general public
and offer courses of varying lengths geared to
health care professionals and the general public.
Over the past three decades the courses have
generally become shorter as a result of attempts
to make CPR easier to perform. For example the
cards following training. Recent versions of the
course also teach about AEDs and how to use them
for cardiac arrest events. Traditionally CPR has
been taught in classroom setting with instructional
movies/videos, demonstrations and practice on
training manikins. In the past 10 years some mass
training demonstrations (and occasionally practice
sessions) have been held at stadium sporting
events during half time.
There is widespread belief that training the general
public how to do CPR is beneficial.
Assessment:
Bystander CPR improves the probability of
surviving cardiac with reported odds ratios of
2.0 to 3.0. The challenge is getting enough of
the population trained so that any given cardiac
arrest will likely have a trained bystander present.
Reaching the demographic most likely to witness a
cardiac arrest, namely elderly adults, has proved
difficult.
current AHA HeartSaver course for laypersons is
approximately 3-4 hours in length. Starting in
2006 the AHA course eliminated mouth-to-mouth
Impact:
This has a potentially huge impact.
ventilation for its layperson HeartSaver course
and emphasizes the importance of initial chest
15
Implementation:
1. Sipsma K, Stubbs BA, Plorde M. Training rates
It is difficult to train enough people, especially
and willingness to perform CPR in King County,
those who are likely to witness a cardiac arrest at
Washington: a community survey. Resuscitation.
home, to have a major impact on cardiac arrest
2011;82:564-7.
survival. This strategy is not without success,
however, as many communities report bystander
In King County 79% of survey respondents
CPR rates of 25%. In some communities, such as
reported ever attending a CPR training class.
Seattle/King County, the rate of bystander CPR is
over 50%.
2. American Heart Association. Heartsaver® CPR
AED – Classroom [Internet]. Dallas, TX; American
Science:
Heart Association; [updated 2013 Apr 29; cited
The evidence for the benefit of bystander CPR
2014 Jan 27]. Available from: http://www.heart.
is observational and published studies use
org/HEARTORG/CPRAndECC/CorporateTraining/
retrospective cohort research design. There are
HeartsaverCourses/Heartsaver-CPR-AED---
no randomized clinical trials of bystander CPR.
Classroom_UCM_303776_Article.jsp.
(such a proposal has been raised (Bardy, NEJM)
but is regarded by many as unethical). It is not
Website providing information on Heartsaver®
possible to measure the quality of the bystander
course.
CPR and one must assume the quality is variable.
Nevertheless virtually all studies of CPR comparing
3. Sasson C, Rogers MA, Dahl J, Kellermann AL.
the presence or absence of bystander CPR before
Predictors of survival from out-of-hospital cardiac
EMS-initiated CPR consistently shows benefit when
arrest: a systematic review and meta-analysis. Circ
someone initiates CPR prior to EMS arrival.
Cardiovasc Qual Outcomes. 2010;3:63-81.
Evidence for the benefit of chest compression
“Overall survival from OHCA has been stable for
only comes from prospective randomized trials in
almost 30 years, as have the strong associations
emergency dispatch centers comparing standard
between key predictors and survival. Because most
chest compression and mouth-to-mouth ventilation
OHCA events are witnessed, efforts to improve
instructions to chest compression only telephone
survival should focus on prompt delivery of
instructions at the time of cardiac arrest calls. (see
interventions of known effectiveness by those who
reference 11 below).
witness the event.” – from abstract
16
4. Ritter G, Wolfe RA, Goldstein S, Landis JR,
training, while retaining CPR effectiveness. The
Vasu CM, Acheson A, Leighton R, Medendrop SV.
goal of these developments is to increase and
The effect of bystander CPR on survival of out-
improve bystander CPR and in turn improve
of-hospital cardiac arrest victims. Am Heart J.
resuscitation.” - from abstract
1985;110:932-7.
7. Spaite DW, Hanlon T, Criss EA, Valenzuela TD,
“When bystander CPR was administered to cardiac
Wright AL, Keeley KT, Meislin HW. Prehospital
arrest victims, 22.9% of the victims survived until
cardiac arrest: the impact of witnessed collapse
they were admitted to the hospital and 11.9%
and bystander CPR in a metropolitan EMS system
were discharged alive. In comparison, the statistics
with short response times. Ann Emerg Med.
for cardiac arrest victims who did not receive
1990;19:1264-9.
bystander CPR were 14.6% and 4.7%, respectively
(p less than 0.001).” – from abstract
“Our data revealed improved survival rates
when bystander CPR was initiated on victims of
5. Yasunaga H, Horiguchi H, Tanabe S, Akahane
witnessed cardiac arrest in an EMS system with
M, Ogawa T, Koike S, Imamura T. Collaborative
short response times.” – from abstract
effects of bystander-initiated cardiopulmonary
resuscitation and prehospital advanced cardiac life
8. Hollenberg J, Svensson L, Rosenqvist M. Out-
support by physicians on survival of out-of-hospital
of-hospital cardiac arrest: 10 years of progress
cardiac arrest: a nationwide population-based
in research and treatment. J Intern Med.
observational study. Crit Care. 2010;14:R199.
2013;273:572-83.
“In this registry-based study, BCPR significantly
“Increased use of bystander CPR training and
improved the survival of OHCA with good cerebral
simplified CPR techniques” listed as key areas for
outcome. ” – from abstract
improving cardiac arrest survival.
6. Bradley SM, Rea TD. Improving bystander
9. Svensson L, Bohm K, Castrèn M, Pettersson
cardiopulmonary resuscitation. Curr Opin Crit Care.
H, Engerström L, Herlitz J, Rosenqvist M.
2011;17:219-24.
Compression-only CPR or standard CPR in
out-of-hospital cardiac arrest. N Engl J Med.
“Recent developments in bystander CPR have
2010;363:434-42.
simplified arrest recognition and improved CPR
17
10. Rea TD, Fahrenbruch C, Culley L, Donohoe
“The quality of chest compressions was significantly
RT, Hambly C, Innes J, Bloomingdale M, Subido
improved following the 2010 AHA guidelines,
C, Romines S, Eisenberg MS. CPR with chest
however, it's more difficult for the rescuer to meet
compression alone or with rescue breathing. N Engl
the guidelines due to the increased fatigue of
J Med. 2010;363:423-33.
rescuer.” - from abstract
The above two prospective studies of T-CPR
13. Anderson ML, Cox M, Al-Khatib SM, Nichol
showed no difference in survival among the chest
G, Thomas KL, Chan PS, Saha-Chaudhuri P,
compression only group compared to the standard
Fosbol EL, Eigel B, Clendenen B, Peterson
CPR group but all categories showed improved
ED. Rates of cardiopulmonary resuscitation
survival with chest compression only. The authors
training in the United States. JAMA Intern Med.
concluded that chest compression only was easier
2014;174:194-201.
to perform and should be the standard method of
T-CPR.
“Annual rates of US CPR training are low and vary
widely across communities…. These data contribute
11. Dumas F, Rea TD, Fahrenbruch C, Rosenqvist
to known geographic disparities in survival of
M, Faxén J, Svensson L, Eisenberg MS, Bohm
cardiac arrest...”- from abstract
K. Chest compression alone cardiopulmonary
resuscitation is associated with better long-term
14. Bobrow BJ, Spaite DW, Berg RA, Stolz U,
survival compared with standard cardiopulmonary
Sanders AB, Kern KB, Vadeboncoeur TF, Clark LL,
resuscitation. Circulation. 2013;127:435-41.
Gallagher JV, Stapczynski JS, LoVecchio F, Mullins
TJ, Humble WO, Ewy GA. Chest compression-only
A prospective trial showed better long term survival
CPR by lay rescuers and survival from out-of-
among the group that received chest compression
hospital cardiac arrest. JAMA. 2010;304:1447-54.
only CPR by telecommunicators.
An observational study showed improved survival
12. Yang Z, Li H, Yu T, Chen C, Xu J, Chu Y, Zhou
among the patients receiving chest compression
T, Jiang L, Huang Z. Quality of chest compressions
only CPR.
during compression-only CPR: a comparative
analysis following the 2005 and 2010 American
Heart Association guidelines. Am J Emerg Med.
2014;32:50-4.
18
2. Use the web and apps to teach CPR
and so many entertaining sites and apps that
the serious message of CPR is easily lost in an
Description:
avalanche of attention grabbing alternatives.
There are many web and smartphone based
apps that show how to perform CPR as well as
Science:
how to operate an AED. The first to offer free
The number of potential viewers is immense
instruction was learncpr.org. This site included
(learncpr.org has had over 3 million views and the
one minute videos showing how to do adult, child,
Resuscitate! app has been downloaded 100,000
and infant CPR as well as how to deal with choking
times). What is not known is whether the viewers
emergencies. Learncpr.org has been viewed by
and users actually learn the skills and whether CPR
millions of people. The American Heart Association
has been performed solely as a result of viewing
also provides free online CPR instruction and the
the sites and apps. There are many images of
Medtronic Foundation offers an interactive training
CPR in the media and it is not possible to measure
scenario. Many phone apps exist and some are
the separate impacts of print, TV, movies, apps,
free. Resuscitate! is a free iOS app with one-
web, and other media. It is likely that web and
minute teaching videos on CPR, Choking, and AED
app CPR instructions help inform the public about
along with a free Android version.
cardiac arrest and provide a general sense of how
to perform CPR (and use an AED). Beyond this it
Assessment:
is not possible to quantify the impact. It is as yet
The web and apps and new media can help inform
unclear whether video based instruction (without
the public about cardiac arrest, CPR and AEDs.
manikin practice) is comparable to teaching using
a manikin. An exploratory study proposed use of
Impact:
Twitter to identify CPR training needs.
The impact is probably large.
Articles:
Implementation:
Relative easy to accomplish and inexpensive
relative to the number of viewers. The challenge
is getting the public to view and use the sites.
1. Saraç L, Ok A. The effects of different
instructional methods on students' acquisition and
retention of cardiopulmonary resuscitation skills.
Resuscitation. 2010; 81:555-61.
There is so much competition for viewers “eyeballs”
19
Laypersons who received initial CPR training on
4. Low D, Clark N, Soar J, Padkin A, Stoneham A,
the web did worse than students in a traditional or
Perkins GD, Nolan J. A randomised control trial
case-based class when follow-up CPR performance
to determine if use of the iResus© application
was measured. This is not surprising given the
on a smart phone improves the performance of
psychomotor skills required for CPR in which actual
an advanced life support provider in a simulated
performance on a manikin would likely help learn
medical emergency. Anaesthesia. 2011;66:255-62.
the skill.
Doctors receiving a smartphone refresher course
2. Ahn JY, Cho GC, Shon YD, Park SM, Kang KH.
scored higher than controls on an advanced life
Effect of a reminder video using a mobile phone
support performance test.
on the retention of CPR and AED skills in lay
responders. Resuscitation. 2011;82:1543-7.
5. Nielsen AM, Isbye DL, Lippert FK, Rasmussen
LS. Can mass education and a television campaign
Lay subjects randomized to receive a refresher
change the attitudes towards cardiopulmonary
mobile phone video plus reminder Short Message
resuscitation in a rural community? Scand J Trauma
Service (SMS) messages performed better CPR and
Resusc Emerg Med. 2013;21:39.
expressed greater willingness to perform bystander
CPR compared to controls.
A television media campaign led to increases in
self-reported willingness to perform CPR and use
3. Magura S, Miller MG, Michael T, Bensley R,
an AED among the public in Denmark.
Burkhardt JT, Puente AC, Sullins C. Novel electronic
refreshers for cardiopulmonary resuscitation: a
6. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary
randomized controlled trial. BMC Emerg Med.
resuscitation on television. Miracles and
2012;12:18.
misinformation. N Engl J Med. 1996;334:1578-82.
CPR refresher courses offered online, by email
A study of depictions of CPR on three popular US
or by text message did not improve CPR training
television shows concludes that survival rates
outcomes in laypersons compared to a mailed
and affected populations are not accurately
brochure, but compliance was low for the electronic
represented.
interventions.
20
7. Blewer AL, Leary M, Esposito EC, Gonzalez M,
of information shared by the public in this forum
Riegel B, Bobrow BJ, Abella BS. Continuous chest
could suggest new approaches for improving
compression cardiopulmonary resuscitation training
resuscitation related education.” - from abstract
promotes rescuer self-confidence and increased
secondary training: a hospital-based randomized
controlled trial. Crit Care Med. 2012;40:787-92.
“Continuous chest compression cardiopulmonary
resuscitation education resulted in a statistically
significant increase in secondary training. This
work suggests that implementation of video selfinstruction training programs using continuous
chest compression cardiopulmonary resuscitation
may confer broader dissemination of life-saving
skills and may promote rescuer comfort with
newly acquired cardiopulmonary resuscitation
knowledge.” - from abstract
8. Bosley JC, Zhao NW, Hill S, Shofer FS, Asch
DA, Becker LB, Merchant RM. Decoding twitter:
Surveillance and trends for cardiac arrest and
resuscitation communication. Resuscitation. 2013
Feb;84:206-12.
“...Twitter can be filtered to identify public
knowledge and information seeking and sharing
about cardiac arrest. To better engage via
social media, health care providers can distill
tweets by user, content, temporal trends, and
message dissemination. Further understanding
3. Telecommunicator CPR
Emergency telecommunicators provide CPR
instruction on the telephone - other terms are
Dispatcher CPR, Dispatcher-Assisted CPR, and
Telephone CPR.
Description:
Telecommunicator CPR (T-CPR) began in King
County in 1981. An optimal set of instructions
was developed using simulated cardiac arrests.
The program led to a dramatic increase in the
rate of bystander CPR. The concept was slow to
catch on nationally but by 2000 the awareness of
the potential of T-CPR generally appreciated and
the AHA endorsed the intervention in its 2006
standards for emergency cardiac care (Reference
5). In 2012 the AHA issued a scientific paper with
specific recommendation on how to implement
T-CPR including performance goals.
Assessment:
T-CPR works and achieves benefit comparable
to that of CPR started by previously trained
bystanders. All studies of T-CPR have used either
before and after study design or retrospective
cohort methodologies. As with the benefit of CPR
21
training in general there has been no randomized
paper by Tom Rea. In this paper the witnessed
study of T-CPR compared to no T-CPR. It is clear
VF cardiac arrest survival was reported for EMS
that some communities have T-CPR programs in
initiated CPR, T-CPR initiated bystander CPR, and
place but are unable to provide rapid instructions
bystander CPR (with no T-CPR). Survival rates
(reference 9). It may be that some proprietary
were highest with the bystander CPR but almost as
computerized assisted dispatch programs (used in
good as with T-CPR. The most recent paper from
emergency dispatch center) are not nimble enough
King County published metrics of percentage of
to allow the rapid recognition of cardiac arrest and
cardiac arrests recognized, the time to recognition
delivery of the instructions.
of cardiac arrest, the percentage of cardiac arrests
that received chest compression, and the time
Impact:
to first compression. A recent report from Korea
T-CPR offers a potentially huge impact.
demonstrated increased bystander CPR and
Implementation:
(reference 8).
improved survival following a program of T-CPR
For T-CPR to reach its potential there must
be performance standards and a QI (Quality
Improvement) program in place to monitor all
cardiac arrest calls and provide feedback in order
to achieve the standards. The metrics published
in King County should serve as national standards
for quality T-CPR programs. It would probably
require a strong mandate from a respected
telecommunicator organization (such as NENA) to
Articles:
1. Eisenberg M, Hallstrom A, Carter W, Cummins
RO, Bergner L, Pierce J. Emergency CPR instruction
via telephone. Am J Pub Health. 1985;75:47-50.
This the first study to demonstrate the value of
T-CPR.
create positive momentum.
2. Carter WB, Eisenberg M, Hallstrom A, Schaeffer
Science:
CPR instruction via telephone. Ann Emerg Med.
The development of the program was described
in a series of articles from King County including
an analysis of times to deliver the instructions as
well as impediments to rapid delivery. The survival
S. Development and implementation of emergency
1984;13:695-700.
A description of how the T-CPR was developed and
validated.
benefit of T-CPR was demonstrated in a 2005
22
3. Rea TD, Eisenberg MS, Culley LL, Becker L.
6. Lewis M, Stubbs BA, Eisenberg MS. Dispatcher-
Dispatcher-assisted cardiopulmonary resuscitation
assisted cardiopulmonary resuscitation:
and survival in cardiac arrest. Circulation.
time to identify cardiac arrest and deliver
2001;104:2513-6.
chest compression instructions. Circulation.
2013;128:1522-30.
Demonstration of survival benefit of bystander CPR
and T-CPR (called dispatcher-assisted CPR in the
Recommendations on performance standards
paper).
based upon actual cardiac arrest calls.
4. Clark JJ, Larsen MP, Culley LL, Graves JR,
7. White L, Rogers J, Bloomingdale M, Fahrenbruch
Eisenberg MS. Incidence of agonal respirations
C, Culley L, Subido C, Eisenberg M, Rea T.
in sudden cardiac arrest. Ann Emerg Med.
Dispatcher-assisted cardiopulmonary resuscitation:
1992;21:1464-7.
risks for patients not in cardiac arrest. Circulation.
2010;121:91-7.
Agonal respirations are present in 55% of
witnessed cardiac arrests (yes, 55%!).
T-CPR is safe.
5. Lerner EB, Rea TD, Bobrow BJ, Acker JE 3rd,
8. Song KJ, Sjhin SD, Park CB, Kim JY, Kim do
Berg RA, Brooks SC, Cone DC, Gay M, Gent LM,
K, Kim CH, Ha SY, Eng Hock Ong M, Bobrow
Mears G, Nadkarni VM, O'Connor RE, Potts J,
BJ, McNally B. Dispatcher-assisted bystander
Sayre MR, Swor RA, Travers AH; American Heart
cardiopulmonary resuscitation in a metropolitan
Association Emergency Cardiovascular Care
city: a before-after population-based study.
Committee; Council on Cardiopulmonary, Critical
Resuscitation. 2014;85:34-41.
Care, Perioperative and Resuscitation. Emergency
medical service dispatch cardiopulmonary
T-CPR was associated with a significant increase
resuscitation prearrival instructions to improve
in bystander CPR and improved survival and
survival from out-of-hospital cardiac arrest: a
neurological recovery.
scientific statement from the American Heart
Association. Circulation. 2012;125:648-55.
A scientific statement from the AHA endorsing
T-CPR.
23
9. Van Vleet LM, Hubble MW. Time to first
Characteristics of HP-CPR
compression using Medical Priority Dispatch
System compression-first dispatcher-assisted
Correct hand position
cardiopulmonary resuscitation protocols. Prehosp
Emerg Care. 2012;16:242-50.
Compression rare of 100-120 per minute
This study shows that it can take 4 minutes to
Depth of compression of at least 2 inches
begin chest compressions in some communities.
Full recoil on the upstroke
4. Improve the quality of CPR provided by
EMS personnel through
high-performance CPR (HP-CPR)
50:50 duty cycle
Ventilation of one second each
Description:
Minimal interruptions of CPR (no pause to exceed
In 2005 the AHA issued new standards for health
10 seconds)
professional CPR. The standards stressed high
quality CPR with minimal interruptions in chest
compression, proper rate of compressions and
Assessment:
depth of compressions, and full recoil of the chest.
HP-CPR appears to improve the likelihood of
In addition the new standards called for periods
successful resuscitation. From a functional point
of two minutes of CPR interspersed with rhythm
of view HP-CPR suspends the dying process
assessments. CPR should resume immediately
and allows other interventions (such as proper
after a defibrillatory shock with no pause to
oxygenation, fluids, medications) to “kick in” and
reassess the rhythm. If a shock is not indicated
allow the next defibrillatory shock to be successful.
the presence of a pulse should ascertained. To
Though totally anecdotal, we have reports of
minimize interruptions of chest compression the
numerous communities training all EMS personnel
paramedics are trained to provide endotracheal
in HP-CPR and achieving a dramatic increase
intubation and place an intravenous line with
survival from VF. For example, Thurston County
ongoing chest compressions.
in Washington, saw their witnessed VF survival
rate increase for 24% to 42% solely as a result
24
of instituting HP-CPR. Eventually monitoring of
parts of the country use alternate terms such as:
hemodynamics may prove to be a useful guide to
choreographed CPR, high-quality CPR, pit-crew
quality CPR.
CPR, high-quality CPR, dance of CPR, and CPR
ballet.
Impact:
HP-CPR has the potential for huge impact.
There are physiologic reasons that HP-CPR
Implementation:
with its attention on rate and depth and full
Since EMS personnel receive annual retraining in
CPR it is fairly easy to train in the new technique
of HP-CPR. There are now good training videos
showing the new technique. We have found that
outperforms the older version of CPR. HP-CPR
recoil lead to higher coronary perfusion pressure
and perfusion to vital organs. The minimization
of interruptions keeps the time of no perfusion
pressure to a minimum.
the secret to maintaining this skill, in addition to
periodic retraining, is an ongoing QI program. A
successful QI program shares the performance
metrics with the EMS personnel who participated in
the resuscitation. Their performance is compared
to the county standard. QI is always used for
improvement and never as a disciplinary tool.
Science:
The major study, which provided support for
the AHA changes, came from King County. This
study analyzed high quality CPR compared to the
prior AHA guidelines. Patients who received high
quality CPR had significantly higher survival rates
compared to the “older” CPR. (survival increased
to 46% from 33%). The term used in Seattle
and King County for this high-quality form of
CPR is high-performance CPR (HP-CPR). Other
Articles:
1. Sayre MR, Cantrell SA, White LJ, Hiestand BC,
Keseg DP, Koser S. Impact of the 2005 American
Heart Association cardiopulmonary resuscitation
and emergency cardiovascular care guidelines on
out-of-hospital cardiac arrest survival. Prehosp
Emerg Care. 2009;13:469-77.
Survival from OOHCA improved with the
implementation of 2005 AHA guidelines for CPR
and ECC. These changes were associated with
improvements in the quality of CPR in one
large city.
2. Vadeboncoeur T, Stolz U, Panchal A, Silver A,
Venuti M, Tobin J, Smith G, Nunez M, Karamooz
M, Spaite D, Bobrow B. Chest compression depth
25
and survival in out-of-hospital cardiac arrest.
arrest resulting from nonshockable arrhythmias.
Resuscitation. 2014;85:182-8.
Circulation. 2012;125:1787-94.
“Deeper chest compressions were associated with
“Outcomes from OHCA resulting from nonshockable
improved survival and functional outcome following
rhythms, although poor by comparison with
OHCA. Our results suggest that adhering to the
shockable rhythm presentations, improved
2010 AHA Guideline-recommended depth of at
significantly after implementation of resuscitation
least 51mm could improve outcomes for victims of
guideline changes, suggesting their potential to
OHCA.” - from abstract
benefit all presentations of OHCA.” - from abstract
3. Rea TD, Helbock M, Perry S, Garcia M, Cloyd
5. Meaney PA, Bobrow BJ, Mancini ME, Christenson
D, Becker L, Eisenberg M. Increasing use of
J, de Caen AR, Bhanji F, Abella BS, Kleinman
cardiopulmonary resuscitation during out-of-
ME, Edelson DP, Berg RA, Aufderheide TP, Menon
hospital ventricular fibrillation arrest: survival
V, Leary M; CPR Quality Summit Investigators,
implications of guideline changes. Circulation.
the American Heart Association Emergency
2006;114:2760-5.
Cardiovascular Care Committee, and the Council
on Cardiopulmonary, Critical Care, Perioperative
“Survival to hospital discharge was significantly
and Resuscitation. Cardiopulmonary resuscitation
greater during the intervention period compared
quality: improving cardiac resuscitation outcomes
with the control period (46% [61/134] versus
both inside and outside the hospital: a consensus
33% [122/374], P=0.008) and corresponded to
statement from the American Heart Association.
a decrease in the interval from shock to start of
Circulation. 2013;128:417-35.
chest compressions (28 versus 7 seconds).” - from
abstract
“There are 5 critical components of high-quality
CPR: minimize interruptions in chest compressions,
4. Kudenchuk PJ, Redshaw JD, Stubbs BA,
provide compressions of adequate rate and depth,
Fahrenbruch CE, Dumas F, Phelps R,
avoid leaning between compressions, and avoid
Blackwood J, Rea TD, Eisenberg MS. Impact of
excessive ventilation.” - from abstract
changes in resuscitation practice on survival and
neurological outcome after out-of-hospital cardiac
26
6. Hinchey PR, Myers JB, Lewis R, De Maio VJ,
8. Friess SH, Sutton RM, Bhalala U, Maltese MR,
Reyer E, Licatese D, Zalkin J, Snyder G; Capital
Naim MY, Bratinov G, Weiland TR 3rd, Garuccio M,
County Research Consortium. Improved out-
Nadkarni VM, Becker LB, Berg RA. Hemodynamic
of-hospital cardiac arrest survival after the
directed cardiopulmonary resuscitation improves
sequential implementation of 2005 AHA guidelines
short-term survival from ventricular fibrillation
for compressions, ventilations, and induced
cardiac arrest. Crit Care Med. 2013;41:2698-704.
hypothermia: the Wake County experience. Ann
Emerg Med. 2010;56:348-57.
Hemodyanmic monitoring may prove to be an even
better guide to good CPR compared to achieving
“In the context of a community-wide focus on
adequate compression depth.
resuscitation, the sequential implementation
of 2005 American Heart Association guidelines
9. Wallace SK, Abella BS, Becker LB. Quantifying
for compressions, ventilations, and induced
the effect of cardiopulmonary resuscitation quality
hypothermia significantly improved survival after
on cardiac arrest outcome: a systematic review
cardiac arrest. Further study is required to clarify
and meta-analysis. Circ Cardiovasc Qual Outcomes.
the relative contribution of each intervention to
2013;6:148-56.
improved survival outcomes.” - from abstract
The proper rate and depth of chest compressions
7. Idris AH, Guffey D, Aufderheide TP, Brown S,
Morrison LJ, Nichols P, Powell J, Daya M, Bigham
are significantly associated with improved cardiac
arrest survival
BL, Atkins DL, Berg R, Davis D, Stiell I, Sopko
G, Nichol G; Resuscitation Outcomes Consortium
(ROC) Investigators. Relationship between chest
compression rates and outcomes from cardiac
arrest. Circulation. 2012;125:3004-12.
“Chest compression rate was not significantly
associated with survival to hospital discharge in
multivariable categorical or cubic spline models,”
but rates over 125 were associated with lower
rates of return of spontaneous circulation.
- from abstract
5. Mandate CPR/AED training in schools
Description:
King County EMS has facilitated CPR training
in high school for many years and recently
Washington State passed a law mandating CPR
and AED education in all high schools. In addition
to Washington State, 14 other states require
CPR training in high school. In some European
countries CPR training is mandatory (Norway
27
for example) and others (Great Britain) are
Science:
considering it.
There are no data about whether mandatory
training increases bystander CPR.
Assessment:
The rational for mandatory training is
straightforward. High school students comprise a
captive audience and the hope is that once trained
the students will remember the skill for life. In
addition the students may inform their parents of
the training and maybe achieve a spillover effect.
The argument against mandatory training is the
time and effort in the school curriculum to provide
the training. School officials claim that they are
approached all the time with “do good” proposals.
Every good proposal added to the curriculum has
an opportunity cost with some other content being
eliminated. Then there is the issue of cost. In
Washington State, the requirement for mandatory
training is an unfunded mandate.
Impact:
The impact is likely high though it will take years
(decades) to be realized.
Implementation:
The cost involves training the teachers to be the
trainers or hiring trainers. Purchasing the training
manikins is an initial large cost.
Articles:
1. Cave DM, Aufderheide TP, Beeson J, Ellison A,
Gregory A, Hazinski MF, Hiratzka LF, Lurie KG,
Morrison LJ, Mosesso VN Jr, Nadkarni V, Potts J,
Samson RA, Sayre MR, Schexnayder SM; American
Heart Association Emergency Cardiovascular Care
Committee; Council on Cardiopulmonary, Critical
Care, Perioperative and Resuscitation; Council
on Cardiovascular Diseases in the Young; Council
on Cardiovascular Nursing; Council on Clinical
Cardiology, and Advocacy Coordinating Committee.
Importance and implementation of training in
cardiopulmonary resuscitation and automated
external defibrillation in schools: a science advisory
from the American Heart Association. Circulation.
2011;123:691-706.
“This statement recommends that training in
CPR and familiarization with automated external
defibrillators (AEDs) should be required elements
of secondary school curricula and provides the
rationale for implementation of CPR training,
as well as guidance in overcoming barriers to
implementation.” - from abstract
28
2. Lotfi K, White L, Rea T, Cobb L, Copass M, Yin L,
5. Berger S, Whitstone BN, Frisbee SJ, Miner JT,
Becker L, Eisenberg M. Cardiac arrest in schools.
Dhala A, Pirrallo RG, Utech LM, Sachdeva RC. Cost-
Circulation. 2007;116:1374-9.
effectiveness of Project ADAM: a project to prevent
sudden cardiac death in high school students.
The epidemiology of cardiac arrests in schools.
Pediatr Cardiol. 2004;25:660-7.
Swor R, Grace H, McGovern H, Weiner M, Walton
Provides details for constructing a model to
E. Cardiac arrests in schools: assessing use of
evaluate the cost effectiveness of school AED
automated external defibrillators (AED) on school
programs in different communities.
campuses. Resuscitation. 2013;84:426-9.
Epidemiology of cardiac arrests in schools using a
national registry.
3. Vetter VL, Haley DM. Secondary prevention of
sudden cardiac death: does it work in children?
Curr Opin Cardiol. 2014;29:68-75.
Reviews current literature on treatment of cardiac
arrest in children, with a focus on school AED
programs. Estimates the impact of effective school
AED programs and suggests best practices.
4. Kovach J, Berger S. Automated external
defibrillators and secondary prevention of sudden
cardiac death among children and adolescents.
Pediatr Cardiol. 2012;33:402-6.
Review of current literature on AED programs in
schools with a suggestion that these programs
improve OHCA outcomes.
6. Automatic CPR devices
Description:
Automatic CPR devices come in two main flavors.
One works through compression of the chest and
the other actually uses a hydraulic device to press
on the sternum.
Assessment:
There may be a limited role for automatic devices
such as long transportation of patients with
ongoing CPR or delays in preparing the cath lab for
cardiac arrest patients with evidence of STEMI.
Impact:
The impact is likely to be small.
Implementation:
The devices are costly and as the ASPIRE study
demonstrated there may be harm with routine use
of the devices.
29
Science:
Rubertsson S, Lindgren E, Smekal D, Östlund O,
There is no convincing demonstration of utility in
Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt
improving outcomes in the prehospital setting.
B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz
J, Karlsten R. Mechanical chest compressions
Articles:
and simultaneous defibrillation vs conventional
Hallstrom A, Rea TD, Sayre MR, Christenson
cardiopulmonary resuscitation in out-of-hospital
J, Anton AR, Mosesso VN Jr, Van Ottingham L,
cardiac arrest: the LINC randomized trial. JAMA.
Olsufka M, Pennington S, White LJ, Yahn S, Husar
2014;311:53-61.
J, Morris MF, Cobb LA. Manual chest compression
vs use of an automated chest compression
This large randomized clinical trial showed no
device during resuscitation following out-of-
difference in survival among the group treated with
hospital cardiac arrest: a randomized trial. JAMA.
the mechanical device compared to the manual
2006;295:2620-2628.
CPR group.
“Use of an automated LDB-CPR device as
Azadi N, Niemann JT, Thomas JL. Coronary imaging
implemented in this study was associated with
and intervention during cardiovascular collapse:
worse neurological outcomes and a trend toward
use of the LUCAS mechanical CPR device in the
worse survival than manual CPR.” – from abstract
cardiac catheterization laboratory. J Invasive
Cardiol. 2012;24:79-83.
Axelsson C, Nestin J, Svensson, L, Axelsson
AB, Herlitz J. Clinical Consequences of the
“This series provides a description of the use of
introduction of mechanical chest compression in
the LUCAS mechanical CPR device and examples
the EMS system for treatment of out-of-hospital
of coronary imaging and intervention during
cardiac arrest – a pilot study. Resuscitation.
mechanical CPR.” – from abstract
2006;71:47-55.
Bonnemeier H, Simonis G, Olivecrona G,
“In this pilot study, the results did not support
Weidtmann B, Götberg M, Weitz G, Gerling I,
the hypothesis that the introduction of mechanical
Strasser R, Frey N. Continuous mechanical chest
chest compression in OHCA improves outcome.” –
compression during in-hospital cardiopulmonary
from abstract
resuscitation of patients with pulseless electrical
activity. Resuscitation. 2011;82:155-9.
30
“Continuous chest compression with an automatic
7. Telecommunicator rapid dispatch
mechanical device is feasible, safe, and might
improve outcomes after in-hospital-resuscitation of
PEA” – from abstract
Wagner H, Terkelsen CJ, Friberg H, Harnek J, Kern
K, Lassen JF, Olivecrona GK. Cardiac arrest in the
catheterisation laboratory: a 5-year experience of
using mechanical chest compressions to facilitate
PCI during prolonged resuscitation efforts.
Resuscitation. 2010;81:383-7.
“The use of mechanical chest compressions in the
catheterisation laboratory allows for continued
PCI or pericardiocentesis despite ongoing cardiac
or circulatory arrest with artificially sustained
circulation.” – from abstract
Risom M, Jørgensen H, Rasmussen LS, Sørensen
AM. Resuscitation, prolonged cardiac arrest, and
an automated chest compression device. J Emerg
Med. 2010;38:481-3.
“Prolonged chest compressions may be necessary
in some cardiac arrests. These cases suggest
that automated chest compression devices may
increase the chance of a favorable outcome in
these rare situations.” – from abstract
Description:
Rapid dispatch refers to dispatching of the firstin unit as soon as it is apparent that EMS help
is needed. Once the unit is en route additional
information about the call can be provided. For
tiered-response EMS systems, additional units
(such as paramedic units) may be added if needed
once the first unit is dispatched. This may seem
obvious and some may wonder why this isn’t done
all the time. But rapid dispatch is the exception
rather than the rule in most dispatch centers. The
reason for the lack of rapid dispatch is the practice
of gathering all available information BEFORE
deciding on the level of response and the priority
of the response. In addition some proprietary
programs require dispatchers work through a
complicated decision tree before EMS personnel
can be dispatched.
Such programs do not allow
for shortcuts. Rapid dispatch is essentially a
short cut dispatching program that strives to
send emergency help as quickly as possible.
Telecommunicators are trained to act when it is
obvious that a medical emergency is present. The
details on the nature of the emergency can be
sorted out later.
31
Assessment:
Schreiber W, Sterz F. Dispatchers impression plus
Rapid dispatch saves time. And this will result in a
Medical Priority Dispatch System reduced dispatch
higher survival rate.
centre times in cases of out of hospital cardiac
arrest. Pre-alert--a prospective, cluster randomized
Impact:
trial. Resuscitation. 2013;84:883-8.
The impact is modest, perhaps a 5% increase in
survival rate though the actual benefit will depend
In a telecommunication center using proprietary
on the time saving.
dispatch protocols, it took over 3 minutes to
dispatch EMS personnel to suspected cardiac
Implementation:
Dispatch centers can decide which conditions
merit rapid dispatch. In King County, the criteria
for rapid dispatch are: suspected cardiac arrest,
unconscious, chest pain, shortness of breath,
ongoing choking, seizure, diabetic hypoglycemia,
stroke symptoms, and major trauma. A reasonable
standard is a median time of 30 seconds from the
call pick up to dispatching the first-in unit for rapid
dispatch conditions.
Science:
There are no studies to prove that rapid dispatch
improves survival though it seems intuitive that the
shortened response time will translate into higher
survival. Anecdotally Seattle Fire Department
instituted a rapid dispatch program in 2013 and
shorted the interval from call received to dispatch of
the first-in unit by 30 seconds.
Articles:
1. Weiser C, van Tulder R, Stöckl M, Schober A,
Herkner H, Chwojka CC, Hopfgartner A, Novosad H,
arrests. When an experimental “pre-alert” system
was implemented, the call processing time was
reduced to approximately 2 minutes.
2. Kuisma M, Boyd J, Väyrynen T, Repo J, NousilaWiik M, Holmström P. Emergency call processing
and survival from out-of-hospital ventricular
fibrillation. Resuscitation. 2005;67:89-93.
Retrospective cohort study showing a nonstatistically significant increase in patient survival
with faster dispatch processing times.
3. Campbell JP, Gridley TS, Muelleman RL.
Measuring response intervals in a system with a
911 primary and an emergency medical services
secondary public safety answering point. Ann
Emerg Med. 1997;29:492-6.
The median call processing time was approximately
2 minutes for calls beginning at a primary public
safety answering point (PSAP) and transferred to a
secondary PSAP.
32
2. Defibrillation
Strategies in this category relate to how to provide
Impact:
defibrillation as quickly as possible and how to
PAD programs have a small but measurable
encourage dissemination of automated external
impact.
defibrillators throughout our society.
Implementation:
1. Increase Public Access Defibrillator
(PAD) programs
The cost is high (AEDs generally sell for $1000$1500 each) and there is maintenance costs of new
batteries and pads (these must be replaced every
2-3 years).
Description:
The PAD concept is to place AEDs throughout
the community – a kind of prepositioning of the
Science:
device – so it can be used prior to the arrival of
Cardiac arrests in public locations comprise
EMS personnel. PAD generally refers to AEDs that
approximately 15% of all cardiac arrests. Among
are placed in public locations. Typical locations are
the public places some type of locations have a
airport and other transportation facilities, exercise
higher incidence of cardiac arrest compared to
facilities, shopping malls, sporting venues, casinos,
other locations. Sites with the highest incidence
community centers. The use of AEDs in public
of cardiac arrest are transportation hubs, jails,
settings is covered by good Samaritan laws.
shopping malls, sporting venues, golf courses,
shelters, exercise facilities, and senior centers.
Assessment:
The logic behind PAD is compelling. The challenges
Articles:
have to do with the minority of cardiac arrests in
Becker L, Eisenberg M, Fahrenbruch C, Cobb L.
public places and the cost of AED not to mention
Public locations of cardiac arrest. Implications
training of personnel and maintenance of pads and
for public access defibrillation. Circulation.
batteries. The actual annual number of cardiac
1998;97:2106-9.
arrests in any given public site is very low.
There
may be some collateral benefit in that the public
“This study described the public locations of
displays of AEDs may sensitize the public to what
cardiac arrest and estimated the annual incidence
AEDs are and the role it plays thus increasing
of cardiac arrest per site to determine optimal
awareness of cardiac arrest and how to respond.
placement of automatic external defibrillators
(AEDs).” - from abstract
33
Culley LL, Rea TD, Murray JA, Welles B,
Rea TD, Olsufka M, Bemis B, White L, Yin L, Becker
Fahrenbruch CE, Olsufka M, Eisenberg MS,
L, Copass M, Eisenberg M, Cobb L. A population-
Copass MK. Public access defibrillation in out-of-
based investigation of public access defibrillation:
hospital cardiac arrest: a community-based study.
role of emergency medical services care.
Circulation. 2004;109:1859-63.
Resuscitation. 2010;81:163-7.
“The EMS of Seattle and King County developed
In King County the use of PAD has increased over
a voluntary Community Responder AED Program
8 years and the most recent study reports 8.8%
and registry of PAD AEDs. During the 4 years,
of all VF cardiac arrests had a PAD attached and
475 AEDs were placed in a variety of settings,
deliver the first shock. It should be pointed out
and more than 4000 persons were trained in
that police application of AEDs in this study were
cardiopulmonary resuscitation and AED operation.
considered to be a PAD use.
The proportion treated by PAD AED increased
each year, from 0.82% in 1999 to 1.12% in 2000,
5. Kilaru AS, Leffer M, Perkner J, Sawyer KF,
1.41% in 2001, and 2.05% in 2002 (P=0.019, test
Jolley CE, Nadkarni LD, Shofer FS, Merchant
for trend).” - from abstract
RM.Use of automated external defibrillators in us
federal buildings: implementation of the Federal
Hallstrom AP, Ornato JP, Weisfeldt M, Travers A,
Occupational Health public access defibrillation
Christenson J, McBurnie MA, Zalenski R, Becker LB,
program. J Occup Environ Med. 2014;56:86-91.
Schron EB, Proschan M; Public Access Defibrillation
Trial Investigators. Public-access defibrillation and
There were 132 events involving an AED, 96 (73%)
survival after out-of-hospital cardiac arrest. N Engl
of which were due to cardiac arrest of cardiac
J Med. 2004;351:637-46.
etiology. Of 54 people who were witnessed to
experience a cardiac arrest and presented with
One randomized trial studied the utility of PAD and
ventricular fibrillation or ventricular tachycardia, 21
found improved survival in the PAD sites compared
(39%) survived to hospital discharge.
to sites without PAD. No cost-effective studies of
PAD have been done.
Deakin CD, Shewry E, Gray HH. Public access
defibrillation remains out of reach for most victims
of out-of-hospital sudden cardiac arrest. Heart.
Epub 2014 Feb 19.
34
The most recent study comes from Hampshire,
A post-market survey of home AED use found the
Great Britian. Deakin et al. describe the role
devices to be safe and effective.
of public access defibrillation in Hampshire
(Heart Journal in press, 2014). Of 1035 cardiac
arrests, only 44 (4.25%) in 34 different locations
involved the caller knowing an AED was present
at the scene and only 18 (1.7%) had an AED
applied before trained personnel arrived. The
authors conclude that PAD has had little impact
on community cardiac arrest survival and is an
unfulfilled promise.
Fedoruk JC, Currie WL, Gobet M. Locations of
cardiac arrest: affirmation for community Public
Access Defibrillation (PAD) Program. Prehosp
Disaster Med. 2002;17:202-5.
“Public Access Defibrillation Programs should
identify the site-specific incidence of arrest within
their communities in order to provide legitimacy
for funding and planning of programs. Training
and availability of AEDs will reduce the time to first
shock, thus strengthening the chain-of-survival and
will save more lives.” - from abstract
8. Jorgenson DB, Yount TB, White RD, Liu PY,
Eisenberg MS, Becker LB. Impacting sudden
cardiac arrest in the home: a safety and
effectiveness study of privately-owned AEDs.
Resuscitation. 2013;84:149-53.
2. Train and equip police with AEDs
Description:
Rochester, MN has pioneered the involvement of
police in responding to cardiac arrests. Since 1990
police have responded along with EMS personnel
to all cardiac arrests – in fact they respond to
all medical emergencies. Thus Rochester has a
three-tiered EMS response system - police, EMT
firefighters, and paramedics. The survival rates
in Rochester are among the highest in the world.
Other communities have tried police defibrillation
programs with varied success.
Assessment:
In any given community there are generally twice
as many police vehicles on the street as there are
EMS vehicles ready for response. Plus police are
“on the street” all hours of the day and night and
there is no call out time to put on gear and leave a
fixed station. Thus police should reach the patient
sooner than EMS personnel. In Rochester this
was achieved in half of cardiac arrests but other
communities reported less success. In King County
the police were involved in a minority of arrests.
The reasons for the underwhelming spread of
police defibrillation are multiple and involve
dispatch center policies, culture, mission, cost,
35
extra training, and availability (this is especially
Articles:
a problem in busy departments). Our experience
White RD, Bunch TJ, Hankins DG. Evolution of a
in King County points to dispatch centers as the
community-wide early defibrillation programme:
largest impediment to effective dispatching of
Experience over 13 years using police/fire
police to cardiac arrests. The tipping point for
personnel and paramedics as responders.
police to be dispatched to all cardiac arrests has
Resuscitation. 2005;65:279-283.
not yet been reached.
After a 2-year pilot in the early 1990s, Rochester,
Impact:
There is high potential to improve survival
assuming there is high acceptance.
Implementation:
Very difficult due to a variety of issues including
dispatch policies, culture, training, cost and
leadership.
Science:
The initial studies from Rochester were
observational in nature but provide compelling
support for police involvement in cardiac arrests. A
literature summary of police AED programs reports
a mixed experience but overall a modest benefit.
King County conducted a prospective pilot of police
AEDs in two communities each with approximately
100,000 persons. The experience in King County
was positive but the magnitude of the benefit was
small.
MN permanently adopted a non-tiered cardiac
arrest response model, where police and EMS
personnel provide CPR and defibrillation to OOHCA
victims. Rochester has one of the highest OOHCA
survival rates in the world.
Myerburg RJ, Fenster J, Velez M, Rosenberg D, Lai
S, Kurlansky P, Starbuck N, Knox M, Castellanos A.
Impact of community-wide police car deployment
of automated external defibrillators on survival
from out-of-hospital cardiac arrest. Circulation.
2002;106:1058-1064.
In Miami-Dade County police vehicles equipped
with AEDs were dispatched simultaneously with
EMS. Response times and survival from VF/
VT rhythms improved significantly after police
defibrillation was implemented.
Mosesso VN, Davis EA, Auble TE, Paris PM, Yealy
DM. Use of automated external defibrillators by
police officers for treatment of out-of-hospital
cardiac arrest. Ann Emerg Med. 1998;32:200-207.
36
Police officers were trained in the use of and
Husain S, Eisenberg M. Police AED programs:
equipped with AEDs in Allegheny County, PA. Time
a systematic review and meta-analysis.
from 9-1-1 call to first defibrillation decreased and
Resuscitation. 2013;84:1184-91.
survival increased significantly in those patients
who were first shocked by police vs. EMS.
This literature review of police AED program
implementation in several communities presents
Groh WJ, Newman MM, Beal PE, Fineberg NS, Zipes
varied results in survival from OOHCA. However,
DP. Limited response to cardiac arrest by police
a meta-analysis of survival and time from 9-1-1
equipped with automated external defibrillators:
call to defibrillation from all communities showed
lack of survival benefit in suburban and rural
significant improvement with police AED programs,
Indiana – the police as responder automated
indicating great potential for the success of these
defibrillation evaluation (PARADE). Acad Emerg
programs.
Med. 2001;8:324-330.
7. Hirsch LM, Wallace SK, Leary M, Tucker
While this community did not see an improvement
KD, Becker LB, Abella BS. Automated external
in survival with police defibrillation, they did find
defibrillator availability and CPR training among
that the time intervals from 9-1-1 call to scene and
state police agencies in the United States.
9-1-1 call to defibrillation were significantly shorter
Ann Emerg Med. 2012;60:57-62.
by 1.6 mins (p=0.05) and 4.8 mins (p=0.008),
respectively.
One third of state police agencies surveyed
equipped their vehicles with automated external
Becker L, Husain S, Kudenchuk P, Doll A, Rea T,
defibrillators, and among those that did, most
Eisenberg M. Treatment of cardiac arrest with rapid
equipped only a minority of their fleet. Most state
defibrillation by police in King County, Washington.
police agencies reported training their officers
Prehosp Emerg Care. 2014;18:22-7.
in automated external defibrillator usage and
CPR. Increasing automated external defibrillator
Two cities in King County, WA implemented a
deployment among state police represents an
2-year pilot of training and equipping police officers
important opportunity to improve first responder
with AEDs. Police involvement in resuscitations
preparedness for cardiac arrest care.
was measurable, but limited, due to challenges in
-From the conclusion
achieving simultaneous police and EMS dispatch.
37
8. Sayre MR, Evans J, White LJ, Brennan TD.
building codes or specific administrative laws is
Providing automated external defibrillators to urban
relative new.
police officers in addition to a fire department
rapid defibrillation program is not effective.
Resuscitation. 2005;66:189-196.
9. van Alem AP, Vrenken RH, de Vos R, Tijssen
JGP, Koster RW. Use of automated external
defibrillator by first responders in out of hospital
cardiac arrest: prospective controlled trial. BMJ.
2003;327:1312-1316.
The above two articles did not find a statistically
significant improvement in survival after the
implementation of their police AED programs.
3. Change building codes to require PADs
Description:
The rationale for building codes requiring AEDs is
based on fire codes requiring sprinklers in public
buildings. Several states require certain public
facilities to have AEDs. For example Florida
requires AEDs at all public and commercial exercise
facilities. The federal government passed a law in
2000 requiring AEDs in federal buildings open to
the public (reference 6).
Impact:
The impact is potentially large but it will take many
years to implement.
Implementation:
The biggest impediment is cost and the resistance
of business who perceive such “safety laws” as
unfunded mandates.
Science:
Other than descriptive studies that define locations
with a high incidence of cardiac arrest there are no
data to support the benefit of mandatory AEDs at
selected sites.
1. Aufderheide T, Hazinski MF, Nichol G, Steffens
SS, Buroker A, McCune R, Stapleton E, Nadkarni
V, Potts J, Ramirez RR, Eigel B, Epstein A, Sayre
M, Halperin H, Cummins RO; American Heart
Association Emergency Cardiovascular Care
Committee; Council on Clinical Cardiology;
Office of State Advocacy. Community lay rescuer
automated external defibrillation programs: key
state legislative components and implementation
strategies: a summary of a decade of experience
Assessment:
for healthcare providers, policymakers,
It makes sense that certain locations should have
legislators, employers, and community leaders
AEDs. The legal route to make it happen through
from the American Heart Association Emergency
38
Cardiovascular Care Committee, Council on
programs. Both concede that PAD programs may
Clinical Cardiology, and Office of State Advocacy.
be effective if AEDs are placed in high impact
Circulation. 2006;113:1260-70.
areas, but the con article argues that these
programs will have little impact at a population
A primer for developing legislation related to public
level.
AED programs, with sample legislation sections
included.
6. National Conference of State Legislatures.
State laws on cardiac arrest and defibrillators:
2. Gilchrist S, Schieb L, Mukhtar Q, Valderrama A,
Encouraging or requiring community access
Zhang G, Yoon P, Schooley M. A summary of public
and use [Internet]. Washington, DC: National
access defibrillation laws, United States, 2010. Prev
Conference of State Legislatures; [updated 2013
Chronic Dis. 2012;9:E71.
Jan; cited 2014 Jan 28]. Available from: http://
www.ncsl.org/research/health/laws-on-cardiac-
3. Atkins DL. Realistic expectations for public
arrest-and-defibrillators-aeds.aspx.
access defibrillation programs. Curr Opin Crit Care.
2010;16:191-5.
Compilation of AED laws in all states. These data
were current as of 2013.
Review of the effectiveness of public access
defibrillation programs, suggesting that targeting
areas with high cardiac arrest incidence is most
4. Register AEDs and notify volunteers of
cardiac arrests and location of AEDs
effective.
4. Gold LS, Eisenberg M. Cost-effectiveness of
automated external defibrillators in public places:
pro. Curr Opin Cardiol. 2007;22:1-4.
5. Pell JP, Walker A, Cobbe SM. Cost-effectiveness
of automated external defibrillators in public
places: con. Curr Opin Cardiol. 2007;22:5-10.
Two articles describing the pros and cons of PAD
Description:
The goal of registering AEDs is for dispatch centers
to have location information and potentially notify
callers of nearby AEDs. This process can be
manual (with the dispatcher verbally describing
the location to the caller) or automated through
web apps (such as PulsePoint – pulsepoint.org).
In the PulsePoint system the recipient (who has
downloaded the app on his or her smart phone)
is sent a map with the location of the arrest
39
and nearby AEDs (which have previously been
that an AED was located in the house – the
registered).
caller had forgotten about the AED – and it was
attached prior to fire department arrival) and of the
Assessment:
The PulsePoint system must be purchased by
a dispatch center if the app is to be integrated
PulsePoint system activation where an app is used
to notify a volunteer that a cardiac arrest is nearby.
There are no data other than the anecdotal reports.
into the dispatch system. PulsePoint currently
only sends alerts about cardiac arrests in public
Articles:
locations. Issues of privacy have limited its use to
1. Rea T, Blackwood J, Damon S, Phelps R,
public events. The PulsePoint Foundation intends
Eisenberg M. A link between emergency dispatch
to conduct a pilot with alerts provided for arrests in
and public access AEDs: potential implications for
private homes. There is a cost for dispatch centers
early defibrillation. Resuscitation. 2011;82:995-8.
to utilize the PulsePoint system. Other limitations
involve the person with a smart phone notification
“A working link between emergency dispatch and
dropping everything and rushing to the site of the
an AED registry may provide an opportunity to
alert (and hopefully picking up a nearby AED).
improve resuscitation.”-from abstract
Impact:
2. Hansen CM, Wissenberg M, Weeke P, Ruwald
This is an evolving technology. Currently it offers
MH, Lamberts M, Lippert FK, Gislason GH, Nielsen
limited utility.
SL, Køber L, Torp-Pedersen C, Folke F. Automated
Implementation:
half of nearby cardiac arrests in public locations
The cost is relatively modest. The PulsePoint
system initially costs a dispatch center about
$10,000 and then about $5,000 annually. There is
no cost to those who download the free app.
Science:
There are a few anecdotal reports of the dispatcher
notifying callers of nearby AEDs (in one event in
external defibrillators inaccessible to more than
during evening, nighttime, and weekends.
Circulation. 2013;128:2224-31.
“Limited AED accessibility at the time of cardiac
arrest decreased AED coverage by 53.4% during
the evening, nighttime, and weekends, which
is when 61.8% of all cardiac arrests in public
locations occurred.” – from abstract
King County the dispatcher informed the caller
40
3. Sakai T, Iwami T, Kitamura T, Nishiyama C,
“Improvements of the SMS alert service by
Kawamura T, Kajino K, Tanaka H, Marukawa
laypersons, the EMS, and through technical
S, Tasaki O, Shiozaki T, Ogura H, Kuwagata Y,
adjustments, could increase the number of
Shimazu T. Effectiveness of the new 'Mobile AED
laypersons who provide early aid.”-from abstract
Map' to find and retrieve an AED: A randomised
controlled trial. Resuscitation. 2011;82:69-73.
6. Leung AC, Asch DA, Lozada KN, Saynisch OB,
Asch JM, Becker N, Griffis HM, Shofer F, Hershey
“Although the new Mobile AED Map reduced the
JC, Hill S, Branas CC, Nichol G, Becker LB,
travel distance to access and retrieve the AED, it
Merchant RM. Where are lifesaving automated
failed to shorten the time.” – from abstract
external defibrillators located and how hard is it
to find them in a large urban city? Resuscitation.
4. Gilchrist S, Schieb L, Mukhtar Q, Valderrama A,
2013;84:910-4.
Zhang G, Yoon P, Schooley M. A summary of public
access defibrillation laws, United States, 2010. Prev
Door-to-door surveying is a feasible, but time-
Chronic Dis. 2012;9:E71.
consuming method for identifying AEDs in high
employment areas. Few buildings reported having
“Policy makers should consider strengthening
AEDs and few permitted visualization, which raises
PAD policies by enacting laws that can reduce the
concerns about AED access. To improve cardiac
time from collapse to shock, such as requiring the
arrest outcomes, efforts are needed to improve the
strategic placement of AEDs in high-risk locations
availability of AEDs, awareness of their location and
or mandatory PAD registries that are coordinated
access to them.
with local EMS and dispatch centers.” - from
abstract
7. Chang AM, Leung AC, Saynisch O, Griffis H,
Hill S, Hershey JC, Becker LB, Asch DA, Seidman
5. Scholten AC, van Manen JG, van der Worp WE,
A, Merchant RM. Using a mobile app and mobile
Ijzerman MJ, Doggen CJ. Early cardiopulmonary
workforce to validate data about emergency public
resuscitation and use of Automated External
health resources. Emerg Med J. Epub 2013 May 10.
Defibrillators by laypersons in out-of-hospital
cardiac arrest using an SMS alert service.
Using social media and crowd sourcing, the
Resuscitation. 2011;82:1273-8.
authors engaged a mobile workforce to complete
identification of AEDs in the community. This was
a pilot, feasibility study.
41
3. Advanced Life Support
Strategies in this category relate to airway
other types of airways (such as LMA) are just as
management and the role of medications.
(or almost as good as) endotracheal intubation.
Advocates for teaching EMTs how to use LMAs
1. Advanced airway management
argue that the skill is easy to teach and will protect
Description:
(A skeptic could say that no advanced airway
There are two issues involving advanced airway
control. The first is whether EMTs should learn the
skill of laryngeal mask airway (LMA) placement
and the second is whether endotracheal intubation
is the preferred advanced airway for paramedics.
The airway control currently provided by EMTs
consists of an oral airway (which does not protect
the airway) and a bag valve mask. The term
advanced airway management refers to protection
of the airway with an endotracheal airway (which
the airway sooner than waiting for paramedics.
is needed and that good bag valve masking is
sufficient.) This issue will likely never be studied
in a controlled fashion, as some type of advanced
airway is considered essential to insure adequate
oxygenation and prevent aspiration. It might
be possible to pilot test EMT placement of LMAs
(perhaps in a before and after fashion or with
contemporaneous controls). There are training cost
and maintenance of skill issues with EMTs using
LMAs.
provides complete protection) or a laryngeal mask
airway (LMA) (which provides generally good
airway control), which are currently provided by
paramedics. In a cardiac arrest, advanced airway
management prevents aspiration of saliva or vomit
and ensures good oxygenation. In some systems
paramedics are authorized to provide paralytic
Impact:
Advanced airways likely improve the outcome from
cardiac arrest through prevention of aspiration
and maintenance of adequate oxygenation.
Theoretically if EMTs can proficiently learn this skill,
there may be an improvement in survival.
medication to facilitate the endotracheal intubation
(especially if the patient has a gag reflex or is
Implementation:
conscious or semi-conscious).
Until there is evidence of EMTs safely using LMAs,
implementation is mostly theoretical. There seem
Assessment:
The debate is not whether endotracheal intubation
to be many strong opinions on the best type of
airway making studies difficult.
(considered the gold standard of airway
management) protects the airway but whether
42
Science:
in patients with out-of-hospital cardiac arrest.
There are several studies measuring the skill of
JAMA. 2013;309:257-66.
paramedics in placing several types of airways.
Some studies have questioned whether paramedics
Large observational study (649,359 patients)
can reliably place endotracheal tubes and others
from Japan found worse neurological outcomes
have shown that paramedics, when properly
for patients treated with an advanced airway
trained, are as proficient as physicians in the
compared to patients receiving basic airway
skill. One study demonstrated that the interval
management.
from collapse to placement of advance airway
was associated with survival. There have been
3. Shin SD, Ahn KO, Song KJ, Park CB, Lee EJ. Out-
no studies directly comparing, in a randomized
of-hospital airway management and cardiac arrest
fashion, endotracheal intubation with LMA or the
outcomes: a propensity score matched analysis.
type of advanced airway with basic airway control
Resuscitation. 2012;83:313-9.
and the relationship to survival. There have been
no studies of EMTs using LMAs,
Data from a national cardiac arrest registry in
Korea indicate that risk-adjusted survival to
Articles:
hospital discharge is no different for endotracheal
1. Soar J, Nolan JP. Airway management in
intubation compared to bag-valve mask ventilation
cardiopulmonary resuscitation. Curr Opin Crit Care.
but that survival to discharge was worse for
2013;19:181-7.
laryngeal mask airway compared to bag-valve
mask ventilation.
Conclusions drawn from large observational studies
comparing basic and advanced airway methods
4. Wang HE, Szydlo D, Stouffer JA, Lin S, Carlson
are mixed and may be influenced by unmeasured
JN, Vaillancourt C, Sears G, Verbeek RP, Fowler R,
confounders. There is sufficient clinical equipoise
Idris AH, Koenig K, Christenson J, Minokadeh A,
to support a randomized trial comparing basic and
Brandt J, Rea T; ROC Investigators. Endotracheal
advanced airway interventions.
intubation versus supraglottic airway insertion
in out-of-hospital cardiac arrest. Resuscitation.
2. Hasegawa K, Hiraide A, Chang Y, Brown DF.
2012;83:1061-6.
Association of prehospital advanced airway
management with neurologic outcome and survival
43
Secondary analysis of data from the ROC PRIMED
trial comparing advanced airway management
7. Wahlen BM, Roewer N, Lange M, Kranke
P. Tracheal intubation and alternative airway
techniques. Successful endotracheal intubation
was associated with better patient outcomes when
compared to supraglottic airway management.
management devices used by healthcare
professionals with different level of preexisting skills: a manikin study. Anaesthesia.
2009;64:549-54.
5. Tanabe S, Ogawa T, Akahane M, Koike S,
Horiguchi H, Yasunaga H, Mizoguchi T, Hatanaka T,
Yokota H, Imamura T. Comparison of neurological
outcome between tracheal intubation and
supraglottic airway device insertion of out-ofhospital cardiac arrest patients: a nationwide,
population-based, observational study. J Emerg
Med. 2013;44:389-97.
Large observational study from Japan finds better
neurological outcomes for patient treated with
endotracheal intubation compared to laryngeal
mask airway or an esophageal obturator airway.
6. Kwok H, Prekker M, Grabinsky A, Carlbom D,
Rea TD. Use of rapid sequence intubation predicts
improved survival among patients intubated after
out-of-hospital cardiac arrest. Resuscitation.
2013;84:1353-8.
Adjusted odds of survival were greater in patients
intubated with parlytics compared to patients
intubated without paralytics. These findings could
explain the adverse relationship between intubation
and survival reported in systems that do not use
paralytic agents.
Paramedics did not perform endotracheal
intubation as well as anesthetists, but their
performance with endotracheal intubation and
other airway management techniques was similar
to performance by other medical professionals.
8. Shy BD, Rea TD, Becker LJ, Eisenberg MS. Time
to intubation and survival in prehospital cardiac
arrest. Prehosp Emerg Care. 2004;8:394-9.
Faster intubation times may increase the odds of
survival in prehospital cardiac arrest.
9. Benger JR, Voss S, Coates D, Greenwood
R, Nolan J, Rawstorne S, Rhys M, Thomas M.
Randomised comparison of the effectiveness of
the laryngeal mask airway supreme, i-gel and
current practice in the initial airway management
of prehospital cardiac arrest (REVIVE-Airways):
a feasibility study research protocol. BMJ Open.
2013;3:e002467.
The protocol for a feasibility study which provides
the template for a large-scale prospective
randomized trial of airway management during
OHCA.
44
2. Medications
Implementation:
Pharmacological therapy is currently the standard
Description:
of care.
It is widely believed that medications are vital to
successful resuscitation. For decades, epinephrine
Science:
and antiarrhythmic medications have been the
A Swedish study compared regular pharmacological
pharmacological workhorses during resuscitation.
therapy (epinephrine and antiarrhythmic
Yet there are no randomized clinical trials showing
medications) with no medication. There was no
the benefit of medications.
difference in survival (references 1 and 2).
Assessment:
Articles:
There are precious little data to support
1. Olasveengen,TM, Sunde K, Brunborg, Thowsen
pharmacological intervention for patients in
J, Steen PA, Wik L. Intravenous drug administration
cardiac arrest. The Resuscitiation Outcomes
during out-of-hospital cardiac arrest: a randomized
Consortium (ROC) Amniodarone, Lidocaine, or
trial. JAMA. 2009;302:2222-9.
neither (Placebo) Study (ALPS) Trial is expected to
finish in 2015 and will provide evidence whether
Prospective trial of 1183 patients with out-of-
antiarrhythmic therapy improves survival from
hospital cardiac arrest who were randomized to
refractory VF (VF which does not convert after one
advanced cardiac life support (ALS) with IV drug
shock).
administration versus ALS without IV drugs.
Patients randomized to IV drugs had higher short-
Impact:
A proven beneficial pharmacological intervention,
assuming it is widely provided, would be very
beneficial. Currently epinephrine is widely used
for all cardiac arrests with many convinced it
is beneficial (see article 2 above). An RCT of
epinephrine versus placebo would be difficult to
perform. The ROC is considering a dose response
term survival, but no improvement in survival to
hospital discharge or long-term survival.
2. Olasveengen TM, Wik L, Sunde J, Steen PA.
Outcome when adrenaline (epinephrine) was
actually given vs not given – post hoc analysis
of a randomized clinical trial. Resuscitation.
2012;83:327-32.
RCT of epinephrine.
45
Retrospective evaluation of trial described
As compared with placebo, amiodarone recipients
in reference #1 above comparing outcomes
had a significantly higher likelihood of survival to
in patients who received epinephrine vs no
hospital admission, but no difference in survival to
epinephrine during ALS care. Recipients of
hospital discharge.
epinephrine had improved short-term survival, but
worse survival to hospital discharge, neurological
5. Dorian P, Cass D, Schwartz B, Cooper R,
status at hospital discharge and one-year survival.
Gelaznikas R, Barr A. Amiodarone as compared
with lidocaine for shock-resistant ventricular
3. Jacobs IG, Finn JC, Jelinek GA, Oxer HF,
fibrillation. N Engl J Med. 2002;346:884-90.
Thompson PL. Effect of adrenaline on survival
in out-of-hospital cardiac arrest: a randomized
Prospective trial of 347 patients with out-of-
double-blind placebo-controlled trial. Resuscitation.
hospital cardiac arrest due to ventricular fibrillation
2011;82:1138-43.
who were randomized to lidocaine or amiodarone.
As compared with lidocaine, amiodarone recipients
Prospective trial of 534 patients with out-of-
were more likely to be admitted alive to hospital,
hospital cardiac arrest who were randomized to
with no differences between the two groups in
epinephrine versus placebo. Epinephrine recipients
survival to hospital discharge.
were more likely to achieve return of spontaneous
circulation, but had no statistically significant
6. Markel DT, Gold LS, Allen J, Fahrenbruch
improvement in surval to hospital discharge.
CE, Rea TD, Eisenberg MS, Kudenchuk PJ.
Procainamide and survival in ventricular fibrillation
4. Kudenchuk PJ, Cobb LA, Copass MK, Cummins
out of hospital cardiac arrest. Acad Emerg Med.
RO, Doherty AM, Fahrenbruch CE, Hallstrom AP,
2010;17:617-23.
Murray WA, Olsufka M, Walsh T. Amiodarone for
resuscitation after out of hospital cardiac arrest
Observational study of 665 patients with out-of-
due to ventricular fibrillation. N Engl J Med.
hospital cardiac arrest due to ventricular fibrillation
1999;341:871-8.
who did or did not receive IV procainamide
as second-line therapy during the course of
Prospective trial of 504 patients with out-of-
resuscitation. Procainamide did not have a
hospital cardiac arrest due to ventricular fibrillation
definitive impact on rates of hospital admission or
who were randomized to amiodarone or placebo in
discharge.
addition to all other standard resuscitation efforts.
46
7. Glover BM, Brown BP, Morrison L, Davis D,
Kudenchuk PJ, Van Ottingham L, Vaillancourt C,
3. Ratio of paramedics to population and
optimal number of EMS responders
Cheskes S, Atkins DL, Dorian P; Resuscitation
Outcomes Consortium Investigators. Wide
Description:
variability in drug use in out-of-hospital cardiac
There is debate in the EMS world about the optimal
arrest: A report from the Resuscitation Outcomes
ratio of paramedics to the population and the
Consortium. Resuscitation. 2012;83:1324-30.
number or responders to a cardiac arrest. The
range of responders is 2-7.
Observational study of drug use among 264
Emergency Medical Service (EMS) agencies
participating in the Resuscitation Outcomes
Consortium, and encompassing more than 16,000
out-of-hospital cardiac arrests. Salient findings
were the considerable variability in drug use among
EMS agencies without a definitive improvement in
survival to hospital discharge.
8. Kudenchuk PJ, Newell C, White L, Fahrenbruch
C, Rea T, Eisenberg M. Prophylactic lidocaine
for post resuscitation care of patients with out
of hospital ventricular fibrillation cardiac arrest.
Resuscitation. 2013;84:1512-8.
Observational study of 1721 patients with
witnessed out-of-hospital cardiac arrest due
to ventricular fibrillation who did or did not
receive prophylactic lidocaine upon first return of
circulation. Prophylactic lidocaine was consistently
associated with a lower incidence of recurrent
cardiac arrest, but without a definitive impact on
survival to hospital admission or discharge.
Assessment:
The ratio of paramedics to population relates to
the issue of skill maintenance. It is assumed that
the more advanced procedures performed - such
as intubation and management of cardiac arrests
- the better the skill. It is very difficult to study
this assumption as skill proficiency results from a
combination of training, continuing education and
repetition.
Impact:
The impact is impossible to determine.
Implementation:
Changing staffing patterns in EMS agencies is
difficult. In many communities EMS vehicles are
staffed with two paramedics or one EMT and one
paramedic. In communities that utilize a tieredresponse the first-in vehicle is usually staffed with
two EMTs and the second-in unit is staffed with two
paramedics.
47
Science:
should be directed at retention efforts to take
There are no data on either issue. A series of
advantage of individual learning by paramedics” -
articles in USA Today described EMS systems
from abstract
in several communities and speculated that
communities with fewer paramedics had higher
4. Nichol G, Detsky AS, Stiell IG, O’Rourke K,
survival rates owing to the higher skill levels.
Wells G, Laupacis A. Effectiveness of emergency
medical services for victims of out-of-hospital
Articles:
1. Davis, R. Fewer paramedics means more lives
saved [Internet]. USA Today; 2006 May 22 [cited
2014 Jan 23]. Available from: http://usatoday30.
usatoday.com/educate/college/healthscience/
cardiac arrest: a meta-analysis. Ann Emerg Med.
1996;27:700-10.
“Increased survival to hospital discharge may be
associated with decreased response time interval
articles/20060528.htm.
and with the use of a two-tier EMS system as
2. Smith MW, Bentley MA, Fernandez AR, Gibson
for this analysis were suboptimal.” - from abstract
G, Schweikhart SB, Woods DD. Performance of
experienced versus less experienced paramedics in
managing challenging scenarios: a cognitive task
analysis study. Ann Emerg Med. 2013;62:367-79.
“...study the cognitive strategies used by expert
paramedics to contribute to understanding how
paramedics and the EMS system can adapt to new
opposed to a one-tier system. The data available
5. Soo LH, Gray D, Young T, Skene A, Hampton JR.
Influence of ambulance crew’s length of experience
on the outcome of out-of-hospital cardiac arrest.
Eur Heart J. 1999;20:535-40.
“Survival from out-of-hospital cardiac arrest varies
with the type of ambulance crew and length of
challenges” – from abstract
experience after qualification. Experience in the
3. David G, Brachet T. Retention, learning by doing,
better survival rates after just 1 year’s experience,
and performance in emergency medical services.
field seems important as paramedics achieve
while technicians need to have more than 4 years’
Health Serv Res. 2009;44:902-25.
experience to improve survival.” - from abstract
“Persistent past and current volume effects suggest
6. Kajino K, Kitamura T, Iwami T, Daya M, Ong
that policy and managerial implications in EMS
ME, Nishiyama C, Sakai T, Tanigawa-Sugihara K,
48
Hayashida S, Nishiuchi T, Hayashi Y, Hiraide A,
Shimazu T. Impact of the number of on-scene
emergency life-saving technicians and outcomes
from out-of-hospital cardiac arrest in Osaka City.
Resuscitation. 2014;85:59-64.
“Compared with the one on-scene ELST group, the
three on-scene ELST group was associated with
the improved one-month survival with favorable
neurological outcome from OHCA in Osaka City.”
– from abstract
49
4. Post-resuscitative Care
Strategies in this category relate to hypothermia
et. al. showed that 36C is comparable to 33C
and resuscitation centers.
in terms of survival and neurological recovery
(reference 9). Nielsen’s study does not answer the
1. Hypothermia
questions of whether 36C is equivalent to ambient
Description:
resuscitation is unclear. Unanswered questions
In 2002 two randomized controlled trials
demonstrated improved survival and neurologic
outcome in patients treated with hypothermia
following successful resuscitation from VF cardiac
air. The role of temperature management post
revolve around controlled 36C versus ambient air
(presumably with active control of fever), timing
of hypothermai (intra-arrest? ED? ICU?), and the
role of hypothermia for in-hospital cardiac arrest.
arrest. Both studies implemented cooling in the
hospital with a goal of 33 degrees Celcius for 24
hours. Compared to patients treated with usual
care (a temperature ~37.3-37.6C), subjects
Impact:
A bit unclear at this point in light of the two recent
studies.
treated with hypothermia had improved survival
and neurological outcome. As a result of these
Implementation:
studies and subsequent supporting retrospective
Certainly for now (until there are more studies)
studies hypothermia was widely used. The initial
36C is a reasonable goal of hospital instituted
trials were only for VF patients but hypothermia
care. This should be easier to implement than
practice spread to all patients, regardless of
hypothermia of 33C.
rhythm, and even for patients prior to arrival at
hospital and even patients who did not even have
return of spontaneous circulation as it is the only
post-resuscitation care modality to be shown to
improve outcome.
Assessment:
The recent trial by Kim et. al. showed that
prehospital hypothermia (administered after return
of spontaneous circulation) is not of therapeutic
benefit (reference 8). The recent trial by Nielsen
Science:
Hypothermia became the standard of care
but questions remain regarding timing, dose
(temperature) and duration.
Articles:
1. Bernard SA, Jones BM, Horne MK. Clinical trial
of induced hypothermia in comatose survivors of
out-of-hospital cardiac arrest. Ann Emerg Med.
1997;30:146-53.
50
Improved outcome for OHCA comatose survivors as
compared with 55 percent in the normothermia
compared to historical controls.
group (76 of 138 patients; risk ratio, 0.74; 95
percent confidence interval, 0.58 to 0.95). The
2. Yanagawa Y, Ishihara S, Norio H, Takino M,
complication rate did not differ significantly between
Kawakami M, Takasu A, Okamoto K, Kaneko N,
the two groups.” - from abstract
Terai C, Okada Y. Preliminary clinical outcome
study of mild resuscitative hypothermia after out-
5. Kim F, Olsufka M, Longstreth WT Jr, Maynard
of-hospital cardiopulmonary arrest. Resuscitation.
C, Carlbom D, Deem S, Kudenchuk P, Copass
1998;39:61-6.
MK, Cobb LA. Pilot randomized clinical trial of
prehospital induction of mild hypothermia in out-
Preliminary study showing improved outcome after
of-hospital cardiac arrest patients with a rapid
OHCA using mild hypothermia.
infusion of 4 degrees C normal saline. Circulation.
2007;115:3064-70.
3. Bernard SA, Gray TW, Buist MD, Jones BM,
Silvester W, Gutteridge G, Smith K. Treatment
“These pilot data suggest that infusion of up to 2 L
of comatose survivors of out-of-hospital cardiac
of 4 degrees C normal saline in the field is feasible,
arrest with induced hypothermia. N Engl J Med.
safe, and effective in lowering temperature. We
2002;346:557-63.
propose that the effect of this cooling method on
neurological outcome after cardiac arrest be studied
“...preliminary observations suggest that treatment
in larger numbers of patients, especially those
with moderate hypothermia appears to improve
whose initial rhythm is ventricular fibrillation.”
outcomes in patients with coma after resuscitation
– from abstract
from out-of-hospital cardiac arrest” - from abstract
6. Bernard SA, Smith K, Cameron P, Masci K,
4. Hypothermia after Cardiac Arrest Study Group.
Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid
Mild therapeutic hypothermia to improve the
Infusion of Cold Hartmanns (RICH) Investigators.
neurologic outcome after cardiac arrest. N Engl J
Induction of therapeutic hypothermia by
Med. 2002;346:549-56.
paramedics after resuscitation from out-of-hospital
ventricular fibrillation cardiac arrest: a randomized
“...Mortality at six months was 41 percent in the
controlled trial. Circulation. 2010;122:737-42.
hypothermia group (56 of 137 patients died), as
51
“In adults who have been resuscitated from out-of-
9. Nielsen N, Wetterslev J, Cronberg T, Erlinge
hospital cardiac arrest with an initial cardiac rhythm
D, Gasche Y, Hassager C, Horn J, Hovdenes J,
of ventricular fibrillation, paramedic cooling with a
Kjaergaard J, Kuiper M, Pellis T, Stammet P,
rapid infusion of large-volume, ice-cold intravenous
Wanscher M, Wise MP, Åneman A, Al-Subaie N,
fluid decreased core temperature at hospital arrival
Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF,
but was not shown to improve outcome at hospital
Hingston CD, Juffermans NP, Koopmans M, Køber
discharge compared with cooling commenced in the
L, Langørgen J, Lilja G, Møller JE, Rundgren M,
hospital.” – from abstract
Rylander C, Smid O, Werer C, Winkel P, Friberg
H; TTM Trial Investigators. Targeted Temperature
7. Diao M, Huang F, Guan J, Zhang Z, Xiao Y,
Management at 33°C versus 36°C after cardiac
Shan Y, Lin Z, Ding L. Prehospital therapeutic
arrest. N Engl J Med. 2013;369:2197-206.
hypothermia after cardiac arrest: a systematic
review and meta-analysis of randomized controlled
“In unconscious survivors of out-of-hospital cardiac
trials. Resuscitation. 2013;84:1021-8.
arrest of presumed cardiac cause, hypothermia at
a targeted temperature of 33°C did not confer a
“quality of evidence is very low” – from abstract
benefit as compared with a targeted temperature of
36°C.” - from abstract
8. Kim F, Nichol G, Maynard C, Hallstrom A,
Kudenchuk PJ, Rea T, Copass MK, Carlbom D, Deem
S, Longstreth WT Jr, Olsufka M, Cobb LA. Effect
of prehospital induction of mild hypothermia on
survival and neurological status among adults with
cardiac arrest: a randomized clinical trial. JAMA.
2014;311:45-52.
“use of prehospital cooling …did not improve
survival or neurological status among patients
resuscitated from prehospital VF or those without
VF.” – from abstract
2. Care mapping
Description:
Care mapping refers to treating cardiac arrest
patients post resuscitation in a standardized fashion
with meticulous blood pressure control, respiratory
status, rhythm managements, fever control, and
treatment of infections.
Assessment:
Care mapping seems to make sense in that
post-resuscitated patients are unstable and
often critically ill. Consistent and attentive
52
post-resuscitation care makes for good clinical
2. Califf RM, Mehta RH, Peterson ED. Clinical quality
practice, especially in the areas of oxygenation,
in non-ST-elevation acute coronary syndromes. Am
ventilation, and hemodynamics.
J Med. 2007;120:930-5.
Impact:
Provides examples on how to create effective
The impact is hard to determine.
guidelines based on a process employed by the
Implementation:
Heart Association. Also presents evidence from
Since post resuscitated patients are all admitted to
intensive care units no extra costs are required.
Science:
This strategy is based on common sense that
good and consistent clinical care will improve
outcomes. Emerging studies have suggested
improved outcomes with meticulous management
of oxygenation, ventilation, and hemodynamics.
Articles:
1. Al-Khatib SM, Fonarow GC, Hayes DL, Curtis
AB, Sears SF Jr, Sanders GD, Hernandez AF,
Mirro MJ, Thomas KL, Eapen ZJ, Russo AM, Yancy
CW. Performance measures to promote quality
improvement in sudden cardiac arrest prevention
and treatment. Am Heart J. 2013;165:862-8.
A summary of current hospital-based performance
measures for treatment of sudden cardiac arrest,
with suggestions for how to select appropriate
performance measures and avoid potential pitfalls.
American College Cardiology and the American
several studies that suggest adherence to
guidelines in hospitals leads to better patient
outcomes.
3. Mehta RH, Peterson ED, Califf RM. Performance
measures have a major effect on cardiovascular
outcomes: a review. Am J Med. 2007;120:398-402.
In a review of studies examining guideline-based
care of patients with coronary artery disease,
the authors found a “dose-response” association
between adherence to guidelines and performance
measures and outcomes.
4. Sunde K, Pytte M, Jacobsen D, Mangschau
A, Jensen LP, Smedsrud C, Draegni T, Steen PA.
Implementation of a standardised treatment
protocol for post resuscitation care after outof-hospital cardiac arrest. Resuscitation.
2007;73:29-39.
Before-after study examining the effect of
implementation of a standardized hospital
53
treatment protocol for out of hospital cardiac arrest
Assessment:
found a significant improvement in discharge with
It would be difficult to study this issue as “sicker
favorable neurological outcome.
patients” may selectively be brought to designated
resuscitation centers. Controlling for patient mix
5. Cox J, Johnstone D, Nemis-White J, Montague
would be difficult.
T; ICONS Investigators. Optimizing healthcare
at the population level: results of the improving
Impact:
cardiovascular outcomes in Nova Scotia partnership.
If data pointed to convincing benefit there may be a
Healthc Q. 2008;11:28-41.
modest improvement in outcomes.
A 5-year, prospective, population-based study
Implementation:
of the effect of evidence-based guidelines and
community partnerships on outcomes for patients
with cardiovascular disease. At the population
level, one-year mortality was not changed, but
outcomes at the individual patient level (e.g. rehospitalization rates, survival) and provider level
(e.g. prescribing patterns) improved.
3. Resuscitation centers
Implementation is a moot issue without better data.
Science:
There are no data to suggest that resuscitation
centers perform better than non-designated
hospitals or that hospitals managing a higher
volume of resuscitated patients fare better than
hospitals with lower volume. The belief that
resuscitation centers may improve outcomes
derives from data pointing to better outcomes
Description:
for hospitals with high volume cardiac surgery
This strategy steers resuscitated patients (or even
compared to hospitals with lower volume.
patients with ongoing CPR) to hospitals with a
high volume of managing resuscitated patients.
Presumably these hospitals might be designated
as resuscitation centers or resuscitation centers
of excellence though there is currently no national
designation of such centers.
Articles:
1. Bosson N, Kaji AH, Niemann JT, Eckstein M, Rashi
P, Tadeo R, Gorospe D, Sung G, French WJ, Shavelle
D, Thomas JL, Koenig W. Survival and neurologic
outcome after out-of-hospital cardiac arrest: results
one year after regionalization of post-cardiac arrest
54
care in a large metropolitan area. Prehosp Emerg
This prospective observational study showed that
Care. Epub 2014 Jan 8.
implementation of a regionalized post-resuscitation
cardiac care system was feasible and clinically
After the implementation of a regionalized cardiac
effective.
care system in Los Angeles County, neurologically
intact survival from OOHCA improved as compared
4. Nichol G, Aufderheide TP, Eigel B, Neumar RW,
to historical data.
Lurie KG, Bufalino VJ, Callaway CW, Menon V, Bass
RR, Abella BS, Sayre M, Dougherty CM, Racht EM,
2. Roberts BW, Kilgannon JH, Mitchell JA, Mittal N,
Kleinman ME, O’Connor RE, Reilly JP, Ossmann
Aji J, Kirchhoff ME, Zanotti S, Parrillo JE, Chansky
EW, Peterson E; American Heart Association
ME, Trzeciak S. Emergency department inter-
Emergency Cardiovascular Care Committee;
hospital transfer for post-cardiac arrest care: initial
Council on Arteriosclerosis, Thrombosis, and
experience with implementation of a regional
Vascular Biology; Council on Cardiopulmonary,
cardiac resuscitation center in the United States.
Critical Care, Perioperative and Resuscitation;
Resuscitation. 2013;84:596-601.
Council on Cardiovascular Nursing; Council on
Clinical Cardiology; Advocacy Committee; Council
Prospective observational study of post-
on Quality of Care and Outcomes Research.
resuscitation OOHCA patients transferred from
Regional systems of care for out-of-hospital cardiac
an ED to a regional cardiac resuscitation center
arrest: A policy statement from the American Heart
(CRC). While the patient sample size was
Association. Circulation. 2010;121:709-29.
small, the researchers found that one-third of
patients transferred to CRCs survived with good
A policy statement from the AHA outlining the
neurological outcome.
justification for regional systems of care for
OOHCA patients. It also describes the need for
3. Heffner AC, Pearson DA, Nussbaum ML, Jones
evidence-based guidelines and standards for the
AE. Regionalization of post-cardiac arrest care:
categorization, verification, and designation of
implementation of a cardiac resuscitation center.
various components of these systems.
Am Heart J. 2012;164:493-501.
55
4. Percutaneous coronary intervention
(PCI)
1. Anyfantakis ZA, Baron G, Aubry P, Himbert D,
Feldman LJ, Juliard JM, Ricard-Hibon A, Burnod A,
Cokkinos DV, Steg PG. Acute coronary angiographic
Description:
findings in survivors of out-of-hospital cardiac
PCI is acknowledged as beneficial for patients with
arrest. Am Heart J. 2009;157:312-8.
proven ST elevation myocardial infarction (STEMI)
as the cause of the cardiac arrest. What is less
Observational study of 72 consecutive patients
clear is the benefit of PCI for patients without
admitted to hospital after out-of-hospital cardiac
STEMI.
arrest (OHCA) who underwent emergency coronary
angiography. About 50% of the patients presented
Assessment:
For patients with ST-elevation, acute coronary
catheterization appears to offer benefit.
Impact:
The impact is likely to be modest.
Implementation:
Implementation is limited by the need for 24/7
staffing of coronary catheterization laboratories.
If cathing became standard of care it would likely
lead to regionalization of post-resuscitation care to
hospitals with cath capability.
Science:
There appears to be a growing consensus that
emergency coronary intervention for acute STelevation myocardial infarction (STEMI) associated
cardiac arrest is warranted and beneficial.
with VF arrest, 32% had ST elevation on hospital
admission, 29% ST depression and 17% had left
bundle branch block (LBBB). The diagnosis of
acute myocardial infarction was established in
27 (37.5%) patients. Of the patients with AMI,
emergency percutaneous coronary intervention
(PCI) was successful in 24 (33%). In a logistic
regression analysis, the presence of coronary
stenosis, recent occlusion or ruptured plaque and
attempted PCI were not independent predictors of
survival, thus making it uncertain whether PCI of
occluded arteries in this patient population confers
a favorable impact on outcome.
2. Hollenbeck RD, McPherson JA, Mooney MR,
Unger BT, Patel NC, McMullan PW Jr, Hsu CH,
Seder DB, Kern KB. Early cardiac catheterization
is associated with improved survival in comatose
survivors of cardiac arrest without STEMI.
Resuscitation. 2014;85:88-95.
56
Observational study of 269 patients with cardiac
(58%) without ST segment elevation.
arrest due to ventricular fibrillation or tachycardia
multivariate analysis, survival to hospital discharge
without associated ST segment elevation of
was significantly higher in recipients of successful
whom were treated with therapeutic hypothermia,
PCI (compared to those with no or failed PCI)
26% of whom in addition received early cardiac
regardless of their ECG presentation (ST segment
catheterization and 29% of whom had late
elevation or not).
catheterization.
In a
An acute coronary occlusion was
discovered in 26% of patients with early cath and
4. Strote JA, Maynard C, Olsufka M, Nichol G,
29% of those receiving late cath; approximately
Copass MK, Cobb LA, Kim F. Comparison of role
one-third of both groups received percutaneous
of early (less than six hours) to later (more than
coronary interventions (PCI). Early cardiac
six hours) or no cardiac catheterization after
catheterization was independently associated with
resuscitation from out-of-hospital cardiac arrest.
a significant improvement in survival to hospital
Am J Cardiol. 2012;109:451-4.
discharge.
Retrospective study of 240 patients with out of
3. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi
hospital cardiac arrest due to ventricular fibrillation
D, Vivien B, Rosencher J, Empana JP, Carli P, Mira
or tachycardia who received early (≤ 6 hours) or
JP, Jouven X, Spaulding C. Immediate percutaneous
deferred (>6 hours) cardiac catheterization after
coronary intervention is associated with better
hospital admission.
survival after out-of-hospital cardiac arrest: insights
than late catheterization were more likely to have
from the PROCAT (Parisian Region Out of hospital
ST segment elevation (75% vs 20%) on ECG, but
Cardiac ArresT) registry. Circ Cardiovasc Interv.
the frequency and extent of identified coronary
2010;3:200-7.
stenoses in those undergoing catheterization were
Recipients of early rather
similar in the two groups.
Percutaneous coronary
Observational study of 714 patients with out-
interventions (PCI) were performed in 62% of
of hospital cardiac arrest, 435 of whom had no
patients in the early group and 7% of those in the
obvious noncardiac cause for arrest and underwent
late catheterization group. In a propensity score-
immediate coronary angiography and percutaneous
adjusted analysis, survival to hospital discharge was
coronary interventions (PCI).
greater in recipients of acute than deferred cardiac
An acute coronary
lesion was found in 128 of 134 patients (96%) with
catheterization.
ST segment elevation and in 176 of 301 patients
57
5. Zanuttini D, Armellini I, Nucifora G, Grillo
a recent coronary artery occlusion, the majority
MT, Morocutti G, Carchietti E, Trillò G, Spedicato
of whom underwent successful angioplasty.
L, Bernardi G, Proclemer A. Predictive value of
Successful angioplasty was an independent
electrocardiogram in diagnosing acute coronary
predictor of improved survival to hospital discharge.
artery lesions among patients with out-of-hospital
cardiac arrest. Resuscitation. 2013;84:1250-4.
7. Dumas F, White L, Stubbs BA, Cariou A, Rea TD.
Long term prognosis following resuscitation from
This study focused on relating the findings on
out-of-hospital cardiac arrest: role of percutaneous
coronary angiography to presenting ECG findings
coronary intervention and therapeutic hypothermia.
in 91 patients with out-of-hospital cardiac arrest.
J Am Coll Cardiol. 2012;60:21-7.
Significant coronary artery disease was found on
angiography in 86% of patients. Presumed acute
Observational study of 5958 patients in King
coronary lesions were identified in 85% of patients
County, WA with attempted resuscitation from
with ST segment elevation and 33% of patients
out-of-hospital cardiac arrest among whom
with other ECG patterns. The study concluded that
short and long-term survival outcomes were
even in the absence of ST segment elevation, acute
compared between recipients of an acute coronary
culprit coronary lesions may be present as the
intervention (PCI) and/or therapeutic hypothermia.
potential trigger for cardiac arrest.
In 80% of patients cardiac arrest was attributable
to a cardiac cause; VF/VT was the presenting
6. Spaulding CM, Joly LM, Rosenberg A, Monchi M,
arrest arrhythmia in 70% of patients. Of the 1001
Weber SN, Dhainaut JF, Carli P. Immediate coronary
patients discharged alive from the hospital, PCI was
angiography in survivors of out-of-hospital cardiac
performed in 38% and therapeutic hypothermia in
arrest. N Engl J Med. 1997;336:1629-33
25%. Receipt of these interventions was associated
with a significantly higher likelihood of survival to
Observational study of 84 patients with no obvious
hospital discharge and survival at 5 years. The
noncardiac cause of out-of-hospital cardiac arrest
combination of PCI and hypothermia achieved
who underwent immediate angiography. The
better outcomes than either intervention alone.
majority of patients had cardiac arrest due to VF/
VT (93%) and had ST segment elevation (42%)
or left bundle branch block (21%) on ECG.
On
angiography, 48% of patients had evidence of
58
5. EMS System
This includes a diverse set of strategies such as
the antecedent events and therapies leading to
a registry for cardiac arrest and medical direction
the outcome. There is currently no mandate
as well as how many responders are needed to
to maintain a registry and there is no national
provide optimal care.
registry. The closest registry to a national registry
is CARES (Cardiac Arrest Registry to Enhance
1. Cardiac arrest registry
Survival). CARES, with initial support from CDC
Description:
100 communities and 6 states participate in CARES
A cardiac arrest registry provides measurement of
and Emory University, started in 2010. Currently
(mycares.net).
current performance and can identify areas within
the system that require modification or change.
If changes are made in the system, whether it
be new protocols, further training, changes in
Impact:
Potentially there is a huge impact with a national
registry.
operating procedures, etc., a registry provides the
documentation of the desired outcomes. Registries
Implementation:
can be simple collections of key demographic
CARES is currently unable to accept new
and performance information (20 or so variables)
communities owing to resource constraints. There
or it can be more comprehensive and involve
is no cost for communities to participate.
numerous variables. The most comprehensive
for CARES comes from a variety of organizations
registries involve research databases with detailed
and foundations.
Funding
data dictionaries maintained by the Resuscitation
Outcomes Consortium communities. One of the
mantras of the Resuscitation Academy is “measure,
improve, measure, improve”. Most EMS programs
in the US do not maintain a registry or participate
in a multi-site registry.
Science:
There are no data showing that cardiac arrest
registries improve community cardiac arrest
survival rates though it is widely believed that
measuring cardiac arrest events and outcomes
is the very first step on the journey to achieve
Assessment:
improvement.
It seems unnecessary to prove such a benefit
since by definition one cannot show improved
outcomes if one doesn’t measure them and
59
Articles:
4. Grasner JT, Herlitz J, Koster RW, Rosell-Ortiz F,
1. Goldberger ZD, Nichol G. Registries to measure
Stamatakis L, Bossaert L. Quality management in
and improve outcomes after cardiac arrest. Curr
resuscitation - towards a European cardiac arrest
Opin Crit Care. 2013;19:208-13.
registry (EuReCa). Resuscitation. 2011;82:989-94.
“OHCA and IHCA registries are invaluable in
advancing our understanding of resuscitation care,
Highlights the differences in key process and
as well as variations in international practice.” -
outcome measures across EMS systems from 5
from abstract
countries. The authors cannot conclude whether the
measured differences truly exist or if they are due
2. Morrison LJ, Nichol G, Rea TD, Christenson J,
to differences in the way data were collected and
Callaway CW, Stephens S, Pirrallo RG, Atkins DL,
measured.
Davis DP, Idris AH, Newgard C; ROC Investigators.
Rationale, development and implementation of the
5. Ong ME, Shin SD, Tanaka H. Pan-Asian
Resuscitation Outcomes Consortium Epistry-Cardiac
Resuscitation Outcomes Study (PAROS): rationale,
Arrest. Resuscitation. 2008;78:161-9.
methodology, and implementation. Acad Emerg
Med. 2011;18:890-7.
Describes the development of the Resuscitation
Outcomes Consortium registry, including the case
Shows that it is possible to establish a large cardiac
definition and description of key variables.
arrest registry in a resource-limited setting.
3. McNally B, Robb R, Mehta M, Vellano K,
2. Cardiac arrest as a reportable condition
Valderrama AL, Yoon PW, Sasson C, Crouch A, Perez
AB, Merritt R, Kellermann A; Centers for Disease
Control and Prevention. Out-of-hospital cardiac
arrest surveillance - Cardiac Arrest Registry to
Enhance Survival (CARES), United States, October
1, 2005-December 31, 2010. MMWR Surveill
Summ. 2011;60:1-19.
Describes the design of the CARES registry and
provides a summary of the data collected during
the first 5 years of existence.
Description:
Making cardiac arrest a reportable condition,
much like many serious transmissible infectious
diseases are reportable, would “jump start” the
participation of EMS systems in cardiac arrest
registries. It is assumed that when communities
see their performance and measure it against other
communities they will be motivated to improve
(assuming peer communities are performing
60
better). Or perhaps a political spotlight shining on
Articles:
the relatively poor performance may bring about
1. Nichol G, Rumsfeld J, Eigel B, Abella BS,
change. For communities currently participating in
Labarthe D, Hong Y, O'Connor RE, Mosesso VN,
the CARES registry they are already reporting all
Berg RA, Leeper BB, Weisfeldt ML; American
cardiac arrests.
Heart Association Emergency Cardiovascular
Care Committee; American Heart Association
Assessment:
Reportable diseases currently fall into the domains
of infectious disease and cancer. Registries are
maintained at the state level and information is
then shared so national surveillance and reporting
can occur.
Impact:
The impact is potentially huge assuming there is
data integrity.
Implementation:
An unfunded mandate for national reporting is likely
to have little value since the integrity of the data
will be less than optimal. For national reporting to
lead to improvements at the local and state level
resources are required to train staff and to maintain
a reporting system.
Science:
There are no data showing a relationship to
outcome. In the infectious disease world, it is
assumed that good reporting of target diseases is
the first step toward understanding and eradication
Council on Cardiopulmonary, Perioperative, and
Critical Care; American Heart Association Council
on Cardiovascular Nursing; American Heart
Association Council on Clinical Cardiology; Quality
of Care and Outcomes Research Interdisciplinary
Working Group. Essential features of designating
out-of-hospital cardiac arrest as a reportable
event: a scientific statement from the American
Heart Association Emergency Cardiovascular
Care Committee; Council on Cardiopulmonary,
Perioperative, and Critical Care; Council on
Cardiovascular Nursing; Council on Clinical
Cardiology; and Quality of Care and Outcomes
Research Interdisciplinary Working Group.
Circulation. 2008;117:2299-308.
2. McNally B, Robb R, Mehta M, Vellano K,
Valderrama AL, Yoon PW, Sasson C, Crouch A, Perez
AB, Merritt R, Kellermann A; Centers for Disease
Control and Prevention. Out-of-hospital cardiac
arrest surveillance - Cardiac Arrest Registry to
Enhance Survival (CARES), United States, October
1, 2005-December 31, 2010. MMWR Surveill
Summ. 2011;60:1-19.
or control.
61
The CARES registry was developed for OOHCA
assumes there is a mechanism for event data to
surveillance, and it serves as an example of a
flow “automatically” to the person responsible for
surveillance registry that can provide benefit in
QI. To maintain a basic QI program for cardiac
evaluating OOHCA trends and ways to improve
arrest in a population of 1 million requires 1 full-
patient care.
time employee. More comprehensive QI programs
that go beyond merely maintenance of a registry
3. Quality improvement (QI) for cardiac
arrest
will require more staff time. For example some
EMS program have QI staff to analyze cardiac
arrest events (ex post facto) and provide summary
Description:
If “measure, improve” is the bedrock for increasing
cardiac arrest survival, then an ongoing QI program
is the vehicle to accomplish measurement.
Assessment:
QI activity can be large or small. At its very least
QI is the means to engage in a cardiac arrest
registry and at the most it is a means providing
detailed feedback to all EMS providers present
during a cardiac arrest.
Impact:
Ongoing QI has the potential to drive improved
performance and thus improve survival rates.
Implementation:
QI is not without cost. A minimal QI program
(for example, in order to maintain a local registry
or to participate in CARES) would require about
one hour of time for every cardiac arrest. This
information about CPR metrics and care provided
to the patient, and hospital outcome information.
Communities with comprehensive QI collect voice
recordings of the resuscitation, all ECG and other
telemetry information, run reports, and hospital
clinical information which are summarized and
provided to the EMS providers.
Science:
There are no data showing a relationship between
quality improvement programs and improved
cardiac arrest survival.
It is widely believed,
however, that measurements achieved through QI
lead to improvements.
Articles:
1. Kwok H, Rea T. Measure and improve.
Resuscitation. 2011;82:645-6.
An argument that measurement is the foundation
for EMS system improvement.
2. van Diepen S, Abella BS, Bobrow BJ, Nichol
62
G, Jollis JG, Mellor J, Racht EM, Yannopoulos D,
Granger CB, Sayre MR. Multistate implementation
5. Bobrow BJ, Vadeboncoeur TF, Clark L, Chikani
of guideline-based cardiac resuscitation systems of
V. Establishing Arizona's statewide cardiac arrest
care: description of the HeartRescue project. Am
reporting and educational network. Prehosp Emerg
Heart J. 2013;166:647-53.
Care. 2008;12:381-7.
Description of a comprehensive effort to implement
“It is feasible for a public health agency to
guideline-based practices across many different
implement a voluntary, statewide data-collection
EMS systems and improve overall survival within 5
system and educational network to determine and
years.
improve survival from OHCA.” - from abstract
3 . Lyon RM, Clarke S, Milligan D, Clegg GR.
6. Berwick DM. Continuous improvement as an ideal
Resuscitation feedback and targeted education
in health care. N Engl J Med. 1989;320:53-6.
improves quality of pre-hospital resuscitation in
Scotland. Resuscitation. 2012;83:70-5.
Incremental changes to the health care process,
rather than changes by individual medical
Analysis and targeted feedback related to the
providers, will lead to improved outcomes.
quality of CPR by prehospital providers led to
improvements in resuscitation quality measures.
4. QI for T-CPR
4. Bobrow BJ, Vadeboncoeur TF, Stolz U, Silver
Description:
AE, Tobin JM, Crawford SA, Mason TK, Schirmer J,
Smith GA, Spaite DW. The influence of scenariobased training and real-time audiovisual feedback
on out-of-hospital cardiopulmonary resuscitation
quality and survival from out-of-hospital cardiac
arrest. Ann Emerg Med. 2013;62:47-56.
A before-after study assessing an initiative to
Quality improvement for T-CPR is the means
to measure performance. Without ongoing QI
the performance standards of T-CPR cannot be
measured. Given the turnover in most dispatching
agencies, constant training and reinforcement about
individual and collective performance is likely to be
necessary.
improve prehospital provider CPR found an
improvement in CPR quality and patient outcomes.
63
Assessment:
Detailed review of TCPR calls with suggestions for
To be effective T-CPRrequires ongoing measurement
metrics that should be measured by all dispatch
and feedback to the call receivers and dispatchers.
agencies.
Impact:
2. Lerner EB, Rea TD, Bobrow BJ, Acker JE 3rd,
If there is meaningful T-CPR QI, there is potential to
Berg RA, Brooks SC, Cone DC, Gay M, Gent LM,
dramatically increase survival rates.
Mears G, Nadkarni VM, O'Connor RE, Potts J,
Sayre MR, Swor RA, Travers AH; American Heart
Implementation:
QI is not without cost. At the very least the
dispatch center must retrieve the digital recording
of the every cardiac arrest call to determine the key
performance metrics. More comprehensive would
be a QI program that provided direct feedback to
the telecommunicators.
Science:
There are no data showing a relationship to
outcome. Measurement requires an ongoing QI
program.
Articles:
1. Lewis M, Stubbs BA, Eisenberg MS. Dispatcherassisted cardiopulmonary resuscitation:
time to identify cardiac arrest and deliver
chest compression instructions. Circulation.
2013;128:1522-30.
Association Emergency Cardiovascular Care
Committee; Council on Cardiopulmonary, Critical
Care, Perioperative and Resuscitation. Emergency
medical service dispatch cardiopulmonary
resuscitation prearrival instructions to improve
survival from out-of-hospital cardiac arrest: a
scientific statement from the American Heart
Association. Circulation. 2012;125:648-55.
How dispatch centers can implement, measure and
monitor their own T-CPR programs.
3. Castrén M, Karlsten R, Lippert F, Christensen
EF, Bovim E, Kvam AM, Robertson-Steel I,
Overton J, Kraft T, Engerstrom L, Garcia-Castrill
Riego L; Emergency Medical Dispatch expert
group at the Utstein Consensus Symposium
2005. Recommended guidelines for reporting on
emergency medical dispatch when conducting
research in emergency medicine: the Utstein style.
Resuscitation. 2008;79:193-7.
64
Extends the Utstein recommendations to include
cardiac arrest, does the provision of dispatch
items all systems should measure to evaluate
cardiopulmonary resuscitation instructions as
dispatch performance during cardiac arrest.
opposed to no instructions improve outcome: a
systematic review of the literature. Resuscitation.
4. Berdowski J, Beekhuis F, Zwinderman AH,
2011;82:1490-5.
Tijssen JG, Koster RW. Importance of the first link:
description and recognition of an out-of-hospital
A review of the current literature does not show
cardiac arrest in an emergency call. Circulation.
a survival benefit for TCPR, but does indicate that
2009;119:2096-102.
bystander CPR rates are improved.
Estimates the incidence of cardiac arrest calls
7. Tanaka Y, Taniguchi J, Wato Y, Yoshida Y, Inaba
among all emergency dispatch calls. Describes the
H. The continuous quality improvement project for
percent correctly identified as cardiac arrest and
telephone-assisted instruction of cardiopulmonary
discusses strategies for improved identification of
resuscitation increased the incidence of bystander
cardiac arrest by call receivers.
CPR and improved the outcomes of out-of-hospital
cardiac arrests. Resuscitation. 2012;83:1235-41.
5. Bobrow BJ, Panczyk M, Subido C. Dispatchassisted cardiopulmonary resuscitation: the anchor
A before-after analysis of a TCPR quality
link in the chain of survival. Curr Opin Crit Care.
improvement program showed improvements in
2012;18:228-33.
bystander CPR rates and patient outcomes.
Focuses on the rationale and evolving science
8. Bradley SM, Fahrenbruch CE, Meischke H, Allen J,
behind dispatch CPR instructions, as well as some
Bloomingdale M, Rea TD. Bystander CPR in out-of-
best practices for implementing and measuring
hospital cardiac arrest: the role of limited English
dispatch-assisted CPR.
proficiency. Resuscitation. 2011;82:680-4.
6. Bohm K, Vaillancourt C, Charette ML, Dunford
Shows how review of TCPR records can identify
J, Castrén M. In patients with out-of-hospital
patient populations that may be underserved.
65
5. Create a culture of excellence
Science:
There are no data showing a relationship between
Description:
The term “culture of excellence” is a cliché, but it
does contain an obvious truth. The expectations
culture of excellence and cardiac arrest survival.
This is primarily because there is no objective way
to define a culture of excellence.
set by the leadership diffuse throughout the
organization. In some EMS organizations, a culture
Articles:
of excellence is typified by the assumption that
1. New York State Emergency Medical Services
every patient in VF will be transported to the
Council. Quality Improvement for Prehospital
hospital with a pulse and blood pressure. When
Providers: Workbook and Guidance Document
they “work” a cardiac arrest, they bring in the
for Service Level and Regional Level Quality
stretcher (during CPR) because they assume the
Improvement Activities [Internet]. New
patient will be resuscitated.
York State Department of Health, Bureau of
Emergency Medical Services; 2007 Mar [cited
Assessment:
Medical and administrative leadership of EMS
organizations range from the excellent to the
terrible. It might be useful for academicians with
business expertise to study EMS systems and help
define the successful and less successful managerial
models.
Impact:
The impact is potentially huge.
Implementation:
There are few proven formulas to create a culture
of excellence. We know it is important but don’t
know how to achieve it. Clearly leadership (medical
and administrative) is a key factor.
2014 Jan 24]. Available from: http://www.
health.ny.gov/8EF8350C-F126-48B5-B528B63D5C9AC83B/FinalDownload/DownloadId-D763C
EA69E35E213743A367DF984F71B/8EF8350C-F12648B5-B528-B63D5C9AC83B/professionals/ems/pdf/
quality_improvement_for_prehospital_providers.
pdf.
Suggests that “Continuous quality improvement”
allows for the maintenance of a “standard of
excellence.”
2. Hagen TM. Five steps to becoming a learning
organization. In times of great change certain
qualities can help an agency thrive. EMS World.
2011;40:91-2.
66
Author poses these qualities to help EMS agencies
for the following 7 areas:
thrive.
1. protocols for EMTs, paramedics, and dispatchers
2. medical supervision - online and offline
3. National Research Council. Emergency Medical
3. evidence-based practice
Services: At the Crossroads [Internet]. Washington,
4. ongoing medical QI
DC: The National Academies Press; 2007 [cited
5. training and continuing education
2014 Jan 23]. Available from: http://books.nap.
6. controlled substance policies
edu/catalog.php?record_id=11629.
7. medical discipline
Statement on the evolution of EMS systems and
Assessment:
quality.
4. National EMS Management Association.
Emergency Medical Services Management and
Leadership Development in America: An Agenda for
the Future [Internet]. National EMS Management
Association; 2008 Oct [cited 2014 Jan 23]. Available
from: http://nemsma.org/Portals/3/NEMSMA%20
Leadership%20Agenda%20FINAL.pdf.
Suggests a link between EMS officers’ management
and patient care.
Lack of a medical model is like playing a symphony
without a conductor. A medical model does
not require that the physician director run the
entire system. In fact, the less administrative
involvement by the medical director, the better.
The medical director should be responsible for
the quality of medical care and establish high
expectations and see that they are being met. The
EMTs and paramedics must be accountable to the
medical director for the quality of their care. The
ideal system would have the administrative director
responsible for budget, operations and personnel
matters and the medical director responsible for
6. Establish a medical model
patient care. And in the best of all words the two
directors would work closely in partnership since
Description:
An EMS system based upon a medical model is one
in which a medical director plays a large role in
determining and supervising the quality of medical
care. Specifically, a medical model of EMS is a
system in which the medical director is responsible
their responsibilities complement each other. The
medical director should not deal with hiring, though
he or she should have a say in who is hired. The
doctor should not fire anyone, though we expect
him or her to work with the administrative director
to limit, suspend, or refuse to medically assume
67
responsibility for an EMT or paramedic whose
appointment and be jointly appointed by the EMS
medical care is substandard. In Seattle and King
administrative director and by the academic dean
County, there is a phrase that encapsulates the
or department chair. An academic appointment
critical role of the medical director: The EMT or
ensures accountability within a larger medical
paramedic practices under the medical license of
community (namely the medical school). Moreover,
the medical director.
an academic physician is generally one who is
In essence, the clinical buck stops with the medical
committed to furthering learning, and one who
director.
probably has knowledge about epidemiological
principles and research methodologies. This is not
Impact:
A strong medical model can have a huge impact on
to say that every medical director must conduct
research – far from it, but only that the director
survival rates.
must understand the benefits and limitations of
Implementation:
interpret) this information. An academic medical
There is no guidebook to follow and probably
many if not most EMS programs think they have
a medical model. The test is whether the medical
director has responsibility for all the seven areas
data, and know how to interpret (and not over
director has access to all the expertise of an
academic medical center and can turn to colleagues
in cardiology, anesthesiology, pediatrics, obstetrics,
trauma surgery, endocrinology, biostatistics,
above.
epidemiology, preventive medicine, health services,
Medical directors are appointed in various ways.
and to seek help in guiding policy.
Whatever the process, the medical director must
have the authority to supervise a system that uses
a medical model of EMS care. The medical director
must clearly state and constantly promote high
expectations, and the EMTs and paramedics must
be accountable to the medical director for their
and toxicology to get answers about clinical issues
For communities that are geographically distant
from an academic medical center, there are
opportunities to create bridges with medical
schools. Many deans and department chairs in
emergency medicine would welcome a conversation
patient care.
with a community’s elected officials or its EMS
It is desirable (though not always possible)
to help establish a clinical appointment for the
that the medical director has an academic
administrative director and would be pleased
community’s medical director.
68
The EMS program can provide training opportunities
2. Williams I, Valderrama AL, Bolton P, Greek A,
for emergency medical residents and help partner
Greer S, Patterson DG, Zhang Z. Factors associated
with the medical school on EMS fellowships. The
with emergency medical services scope of practice
medical center can provide clinical expertise,
for acute cardiovascular events. Prehosp Emerg
communications expertise, database management,
Care. 2012;16:189-97.
and managerial experience and can cooperate
with local medical directors to establish regional
“We noted statistically significant variations in
consortia of EMS medical directors and programs.
scope of practice by rural vs. urban setting, medical
An academic medical center, after all, has a mission
director involvement, and type of EMS service”-
to serve the larger community, and the goodwill and
from abstract
reciprocity generated by this kind of effort can reap
big dividends.
3. U.S. Department of Homeland Security, Federal
Emergency Management Agency, U.S. Fire
Science:
There are no studies of the relationship of the
medical model or medical (or administrative)
leadership and the quality of the EMS program.
Articles:
1. Greer S, Williams I, Valderrama AL, Bolton P,
Patterson DG, Zhang Z. EMS medical direction
and prehospital practices for acute cardiovascular
Administration. Handbook for EMS Medical Directors
[Internet]. 2012 Mar [cited 2014 Jan 24]. Available
from: http://www.usfa.fema.gov/downloads/pdf/
publications/handbook_for_ems_medical_directors.
pdf.
Describes roles of EMS medical directors and
models of EMS systems
events. Prehosp Emerg Care. 2013;17:38-45.
4. American College of Emergency Physicians.
“…study demonstrated that EMS agencies with a
Policy statement. Ann Emerg Med. 2012;60:676-7.
paid medical director and agencies with medical
director interaction with EMTs in the previous
four weeks were more likely to have prehospital
cardiovascular procedures in place” - from abstract
Medical direction of emergency medical services.
5. Cunningham CA, Wesley K, Peterson TD, Alcorta
R, Kupas DF, Nelson JA, Taillac P, Upchurch J. The
role of state medical direction in the comprehensive
emergency medical services system: a resource
document. Prehosp Emerg Care. 2010;14:404-11.
69
“…resource document provides a snapshot of
the status of state EMS medical direction” - from
abstract
6. Brice JH, Perina DG, Liu JM, Braude DA, Rinnert
KJ, Macdonald RD. Development of an EMS
Curriculum. Prehosp Emerg Care. 2014;18:98-105.
This paper describes a curriculum for physician
fellowship program for training in EMS core content.
7. EMS Examination Task Force; American Board of
Emergency Medicine, Perina DG, Pons PT, Blackwell
TH, Bogucki S, Brice JH, Cunningham CA, Delbridge
TR, Gausche-Hill M, Gerard WC, Gratton MC,
Mosesso VN Jr, Pirrallo RG, Rinnert KJ, Sahni R,
Harvey AL, Kowalenko T, Buckendahl CW, O'Leary
LS, Stokes M. The core content of emergency
medical services medicine. Prehosp Emerg Care.
2012;16:309-22.
American Board of Medical Specialties (ABMS)
develops “core content” for emergency medical
services (EMS) as a subspecialty of emergency
medicine.
70
6. Future Approaches
This category considers potentially promising but
detect a transition in the rhythm from an organized
as yet unproven therapies for SCA.
rhythm to VF would allow immediate shock if
1. Develop defibrillators that can
accurately detect the underlying cardiac
rhythm while CPR is being performed.
Description:
An AED that can detect VF with ongoing CPR would
eliminate the need for pauses in CPR to determine
rhythm. Current AEDs require that CPR cease for
the algorithms to determine if VF is present. The
time for this determination varies but can range
from 10-15 seconds. If charging is required
after VF is determined to be present, it may take
another 10-15 seconds for the capacitor to fully
charge. Thus the interval of no CPR can be up
to 30 seconds before a shock can be delivered.
The CPR fraction is an important predictor of
which patients will achieve ROSC and survival.
CPR fractions of 90% are targeted but difficult
to achieve due to pauses. If the rhythm could be
known and continuously available, the rescuer
could charge during CPR and pause only for shock
delivery (< 5 sec.). In addition, if an organized
rhythm is achieved after shock and CPR is resumed
until a pulse can be detected, then CPR artifact
often masks the underlying rhythm which means
the rescuer might not be aware of a refibrillation
until the next time they pause for a rhythm check.
The ability to monitor the patient during CPR and
desired. Furthermore the ability to monitor the
rhythm during CPR allows therapeutic interventions
to be anticipated and preparations to be made
to apply them without stopping CPR for rhythm
confirmation.
Impact:
Modest – such a technological advance would
have no downside and might improve survival by
reducing the amount of hands-off time (lack of
chest compression) during a resuscitation.
Implementation:
It would be useful to demonstrate that such
algorithms reduce the hands-off time during a
resuscitation. More definitive proof would be a
randomized clinical trial to measure the survival
benefit. This would require a very large clinical
trial and may not be warranted given the known
physiology of cardiac arrest. If time could be saved
such innovative technology would likely become
standard of care for future defibrillators.
Science:
The methods to read through the ECG artifact to
determine the underlying rhythm are currently
under intense development (Articles 1-9 below). A
method which uses cross-correlations of the ECG
signal during CPR with a range of interrogating
71
waveforms has been developed by the Center
Articles:
for Progress in Resuscitation at the University
1. Coult J, Neils C, Eisenberg M, Rea T,
of Washington (a collaboration of Medicine,
Kudenchuk PJ, Sherman LD, inventors;
Bioengineering, Electrical Engineering, and Public
University of Washington through its Center
Health) (reference 1). This method has been
for Commercialization, assignee. Systems and
licensed to Philips Healthcare and is in the process
methods for analyzing electrocardiograms to
of being tested for FDA certification. Preliminary
detect ventricular fibrillation. World patent
results demonstrate a 94% sensitivity for detecting
WO/2013/003852. 2013 Mar 1. English.
VF during CPR and greater than 98% specificity.
When employed in continuous analysis of the ECG,
This is the patent describing the method for using
this method should allow confident knowledge
cross-correlations to determine the rhythm during
of the rhythm at all times. Clinical availability is
CPR.
expected in some AED models within the next year.
2. Eilevstjonn J, Eftestol T, Aase SO, Myklebust H,
Summary:
The use of this technology in defibrillators should
soon be available. Other current published and
proprietary methods employ filtering, wavelet
analysis, and subtractive techniques. With the
exception of the cross-correlation method, most
methods have not proven accurate enough to
eliminate the requirement for pauses to confirm the
rhythm prior to shock or other interventions. When
the ability to accurately determine the underlying
rhythm during CPR is available, new protocols
will need to be developed to take advantage
of the ability to anticipate the next therapeutic
intervention based on real time knowledge of the
cardiac rhythm.
Husoy JH, Steen PA. Feasability of shock advice
analysis during CPR through the removal of CPR
artefacts from the human ECG. Resuscitation.
2004;61:131-41.
Describes the use of an ‘adaptive matching pursuit’
algorithm for artefact removal with 97% sensitivity
for VF and 79% specificity for non-shockable
rhythms.
3. Ruiz J, Ayala U, Ruiz de Gauna S, Irusta U,
Gonzalez-Otero D. Alonsa E, Kramer-Hohansen
J, Eftestol T. Feasibility of automated rhythm
assessment in chest compression pauses during
cardiopulmonary resuscitation. Resuscitation.
2013;84;1223-8.
72
Presents a method for analyzing the pauses for
Description of a method using only the ECG
ventilations and is able to achieve a sensitivity
voltages with a Kalman filter tested on human data
of 96% for VF and a specificity of 97% for non-
with 90% sensitivity for VF and 80% specificity for
shockable rhythms
non-shockable rhythms.
4. Amann A, Klotz A, Niederklapfer T, Kupferthaler
7. Langhelle A, Eftestol T, Myklebust H, Eriksen
A, Werther T, Granegger M, Lederer W, Baubin
M, Holten BT, Steen PA. Reducing CPR artefacts
M, Lingnau W. Reduction of CPR artifacts in
in ventricular fibrillation in vitro. Resuscitation.
the ventricular fibrillation ECG by coherent line
2001;48:279-91.
removal. Biomed Eng Online. 2010,9:2.
The use of a digital adaptive filter to remove CPR
Describes the use of a ‘windowed Fourier
artifact in a model system of human VF corrupted
transform’ to improve the signal to noise ratio of
by CPR artifact which has been added to it.
the VF from the CPR artifact.
8. Aramendi E, Ruiz J, Ruiz de Gauna S, Irusta U,
5. Berger RD, Palazzolo J, Halperin H. Rhythm
Lazkano A, Gutierrez J. A simple effective filtering
discrimination during uninterrupted CPR using
method for removing CPR caused by artefacts from
motion artifact reduction system. Resuscitation.
surface ECG signals. Computers in Cardiology.
2007;75:145-52.
2005;32:547-50.
This paper describes a technique in which the force
Describes the use of a notch filter set at the
measurements from a pad under the rescuers
frequency of chest compression delivery to remove
hands during CPR are fed back into the system and
those frequencies and leave other frequencies
subtracted from the ECG voltage values to increase
characteristic of VF untouched and a 90%
the ability to detect VF during CPR.
sensitivity for VF is obtained.
6. Ruiz de Gauna S, Ruiz J, Irusta U, Aramendi E,
9. Li Y, Tang W. Techniques for artefact filtering
Eftestol T, Kramer-Johansen J. A method to remove
from chest compression corrupted ECG signals:
CPR artifacts from human ECG using only the
good, but not good enough. Resuscitation.
recorded ECG. Resuscitation. 2008;76:271-8.
2009;80:1219-20.
73
A survey of methods with discussion of the inability
to enhance the response to shock. Epinephrine is
to obtain a specificity for non-shockable rhythms of
presumed to be beneficial. Measures of cardiac
over 90% (95% is required by AHA/FDA).
physiology result in prediction of when the heart will
best respond to shock. These tests will guide the
2. Develop defibrillators to intelligently
guide therapy (shock or continued CPR)
way to comparing therapies and indicating which
therapies are helping in any given situation and
which are not. New therapeutic strategies should
Description:
emerge from this experience.
Most initial shocks are unsuccessful in defibrillating
the heart, or the initial shock may be successful
Impact:
but last only seconds until the heart refibrillates.
An intelligent defibrillator would have a large impact
Defibrillator intelligent therapy would “read” the
on survival rates.
current VF waveform and based on information
contained in the waveform recommend immediate
Implementation:
shock or advise a period of CPR. The intelligent
As a software upgrade it could be possible to
therapy could continue to read the waveform in real
implement this rapidly. The software may require
time and advise when the myocardial physiology
some changes in the signal processing framework,
was improved sufficiently to provide a durable and
processors and noise reduction improvements
sustained conversion to a perfusing rhythm.
of current defibrillators. Smaller units similar to
pulse oximeter “add ons” might also be possible to
Assessment:
upgrade older models. If the improvement in care is
Such an intelligent defibrillator would be a welcome
perceived as great enough, this would motivate the
enhancement to the resuscitation armamentarium.
process of upgrading units currently in the field.
Presumably the intelligent defibrillator would be
able to calculate real time probabilities of any given
Science:
shock being successful. Thus EMS personnel could
When survival rates in large VF resuscitation
see if the likelihood of success is rising or falling
series are stratified by EMS response times, the
and adjust their therapy to try to maximize a
survival for those whose response times are over
higher likelihood of success. In addition, there are
4 minutes is 15% to lower if shock is delivered
few proven strategies to improve survival beyond
as initial therapy when compared to CPR for 2
providing shock as early as possible and using CPR
to 3 minutes prior to shock. Since it is difficult
74
to clinically determine the prior duration of VF
needed to achieve increased accuracy and proof
in any single case it would be useful to have a
of effect on outcome will be required to catalyze
measure that could identify those likely to respond
the transition to predictive algorithms and new
to shock with an organized rhythm based on the
therapies based on them.
ECG waveform features. Methods to do this have
been developed and are based on the amplitude,
frequency as determined by spectral analysis
methods, and fractal dimension (a quantitative
measure of ‘roughness’). The current science has
the ability to stratify the probability of return of
organized rhythm, return of spontaneous circulation
and survival into groups to help guide therapy
(CPR versus shock as initial therapy) but have yet
to be proven to increase survival long term. The
receiver operator characteristic curve (Resuscitation
Outcomes Consortium) of these methods
are approximately 0.85 to 0.90 and further
improvements are possible. A reliable measure
which would directly indicate the physiologic state
of the myocardium could be used to follow the
progress of therapies during the resuscitation and
provide guidance as to when defibrillation should be
applied with the expectation of having the greatest
probability of conversion to a durable lasting
perfusing cardiac rhythm.
Articles:
1. Callaway CW, Sherman LD, Mosesso VN Jr,
Dietrich TJ, Holt E, Clarkson MC. Scaling exponent
predicts defibrillation success for out-of-hospital
ventricular fibrillation cardiac arrest. Circulation.
2001;103:1656-61.
The fractal dimension can be used to predict
defibrillation success in VF arrest.
2. Menegazzi JJ, Callaway CW, Sherman LD, Hostler
DP, Wang HE, Fertig KC, Logue ES. Ventricular
fibrillation scaling exponent can guide timing of
defibrillation and other therapies. Circulation.
2004;109:926-31.
The fractal dimension (which measures roughness
of VF) is predictive of response to defibrillation.
3. Eftestøl T, Wik L, Sunde K, Steen PA. Effects
of cardiopulmonary resuscitation on predictors
Summary:
There have been several efforts to develop a score
predicting likelihood of shock success. Improvement
in survival based on these methods has not yet
of ventricular fibrillation defibrillation success
during out-of-hospital cardiac arrest. Circulation.
2004;110:10-5.
been achieved. Improvement in the algorithms are
75
In patients with CPR lasting over 3 minutes there is
an improvement in waveform measures indicating
3. Develop an inexpensive “consumer”
defibrillator
a positive effect of CPR on myocardium. The
study demonstrates a rapid decline in frequency
Description:
measures during 10 to 20 second pauses in chest
If one considers an AED as a ubiquitous public
compression.
safety device then it follows that it should be
available in almost every setting. Currently the cost
4. Shandilya S, Ward K, Kurz M, Najarian K.
of the AED and the lack of public appreciation of
Characterization for prediction of defibrillation
cardiac arrest prevent such a model of widespread,
success through machine learning. BMC Med
personal AED deployment.
Inform Decis Mak. 2012;12:116
The use of wavelet analysis with sophisticated
machine learning algorithms is shown to produce
a ROC curve with AUC of 85% when used alone
and of 94% when used with end tidal CO2
measurements.
5. Nakagawa Y, Sato Y, Kojima T, Wakabayashi
T, Morita S, Amino M, Inokuchi S. Electrical
defibrillation outcome prediction by waveform
analysis of ventricular fibrillation in cardiac arrest
out of hospital patients. Tokai J Exp Clin Med.
2012;37:1-5.
The use of Amplitude Spectrum Area (AMSA) to
predict outcomes is described.
Assessment:
Prevention of fires and the acceptance of smoke
detectors may illuminate the situation with cardiac
arrest. Many homes and businesses are equipped
with smoke alarms and fire extinguishers even
though the risk that a given structure will catch
fire is exceptionally small. The fire extinguisher is
not engineered to replace professional firefighting
equipment, but rather intended as a practical
intervention that may successfully treat the fire
in its early stages. In combination, the cost of
residential smoke alarms and extinguisher might be
$100-200.
Impact:
The impact would be potentially huge.
Implementation:
Not applicable at this time
76
Science:
Longstreth WT Jr, Anderson J, Johnson G, Bischoff
Such devices do not currently exist.
E, Yallop JJ, McNulty S, Ray LD, Clapp-Channing NE,
Rosenberg Y, Schron EB; HAT Investigators. Home
Articles:
use of automated external defibrillators for sudden
1. Cram P, Vijan S, Katz D, Fendrick AM. Cost-
cardiac arrest. N Engl J Med. 2008;358:1793-804.
effectiveness of in-home automated external
defibrillators for individuals at increased risk
“For survivors of anterior-wall myocardial infarction
of sudden cardiac death. J Gen Intern Med.
who were not candidates for implantation of a
2005;20:251-8.
cardioverter-defibrillator, access to a home AED
did not significantly improve overall survival,
“The cost-effectiveness of in-home AEDs is
as compared with reliance on conventional
intimately linked to individuals’ risk of SCD.
resuscitation methods. (ClinicalTrials.gov number,
However, providing in-home AEDs to all adults
NCT00047411 [ClinicalTrials.gov].)” - from abstract
over age 60 appears relatively expensive.” - from
abstract
4. National Conference of State Legislatures. State
Laws on Cardiac Arrest and Defibrillators [Internet].
2. Cram P, Katz D, Vijan S, Kent DM, Langa KM,
Washington, DC: National Conference of State
Fendrick AM. Implantable or external defibrillators
Legislatures; [updated 2013 Jan; cited 2014 Jan
for individuals at increased risk of cardiac arrest:
24]. Available from: http://www.ncsl.org/research/
where cost-effectiveness hits fiscal reality. Value
health/laws-on-cardiac-arrest-and-defibrillators-
Health. 2006;9:292-302.
aeds.aspx.
“If financial constraints were to lead to rationing of
Recounts legislation and the impact of AED cost on
defibrillators, it might be preferable to provide more
feasibility for public or home use.
people with a less effective and less expensive
intervention (in-home AEDs) instead of providing
5. Mayo Clinic Staff. Automated external
fewer people with a more effective and more costly
defibrillators: Do you need an AED? [Internet].
intervention (ICDs).” - from abstract
Rochester, MN: Mayo Foundation for Medical
Education and Research; 2011 Jun 10 [cited 2014
3. Bardy GH, Lee KL, Mark DB, Poole JE, Toff WD,
Jan 24]. Available from: http://www.mayoclinic.
Tonkin AM, Smith W, Dorian P, Packer DL, White RD,
org/diseases-conditions/heart-arrhythmia/in-depth/
automated-external-defibrillators/ART-20043909.
77
6. Consumer Reports. Should you buy a home
arrest, layperson AED use does not prevent EMS
defibrillator? [Internet]. Washington, DC: Consumer
response so that standard care is still operational.
Reports; [updated 2009 Jan; cited 2014 Jan 24].
Indeed EMS routinely has an active role in patients
Available from: http://www.consumerreports.org/
treated by layperson AED (reference 5). Thus, the
cro/2012/05/should-you-buy-a-home-defibrillator/
deployment of a “cheap” personal AED with these
index.htm.
distinct operating specifications would have a high
likelihood to improve care, and a small chance that
the patient receives the status-quo standard of care
4. Change FDA classification of public defibrillators
when there is a critical AED failure. If we consider
the current status of community resuscitation which is the greater shortcoming: a cheap AED
Description:
Current AEDs cost approximately $1,000 to $1,500.
The materials to manufacture a personal AED are
available and could support a cost of $100-$200.
Yet AED convention - driven in part by safety
concerns and regulation - introduces substantial
expense so that AEDs typically cost many times
the production costs. Could we consider a different
paradigm that might enable a low-cost AED that
that suffers a 2% failure rate but could “change
the rules” and truly accelerate AED dissemination,
and in turn enable a much broader reach of early
defibrillation, while still providing for the status
quo under the worst case scenario…. or the current
strategy that realizes the AED promise in only a
handful of cases using near-perfect technology that
routinely outdistances the clinical requirements of
the single-shock, layperson AED resuscitation?
would have a more limited scope of therapy and
less rigorous performance standards? What would
Impact:
be the consequence if a “cheap” personal AED
This would have a potentially huge impact as it
was engineered to provide only a single shock and
would facilitate dissemination of AEDs.
would tolerate a 2% critical-failure rate?
Implementation:
Assessment:
Not applicable at this time.
The smoke alarm and fire extinguisher enable early
treatment but do not prevent professional response
from the fire department. Similarly in cardiac
78
Science:
2013 May 20 [cited 2014 Jan 24]. Available from:
It is unclear if such a classification change will
http://www.pharmamedtechbi.com/~/media/
occur.
Supporting%20Documents/The%20Gray%20
Sheet/39/27/Readiness_Systems_Comment.pdf.
Articles:
1. Jefferson E. FDA issues proposal to improve
One argument against the AED reclassification to
the quality of automated external defibrillators
Class III, as submitted for official FDA review.
[Internet]. Silver Spring, MD: U.S. Food and Drug
Administration;
2013 Mar 22 [cited 2014 Jan 24].
4. McCallion, T. FDA Reconsiders Classification of
Available from: http://www.fda.gov/NewsEvents/
AEDs: Expert panel recommends higher safety
Newsroom/PressAnnouncements/ucm345062.htm.
standards [Internet]. Tulsa, OK: JEMS; 2012 Nov
19 [cited 2014 Jan 24]. Available from: http://www.
FDA announcement of AED regulation.
jems.com/article/news/AEDreclassification.
2. Lazar, RA. AED Reclassification – When Near
Synopsis of Proposed 2013 FDA recommendation to
Perfect Is Not Enough for the FDA [Internet].
make AEDs a Class III device.
Readiness Systems, LLC; 2013 May 15 [cited 2014
Jan 24]. Available from: http://www.readisys.com/
5. EMSWorld.com News. FDA Mulls Reclassifying
aed-reclassification-when-near-perfect-is-not-
AEDs, Costs Expected to Rise [Internet]. EMS
enough-for-the-fda/.
World; 2012 Nov 1 [cited 2014 Jan 24]. Available
from: http://www.emsworld.com/news/10823747/
Opinion piece on why FDA should not make AEDs a
fda-mulls-reclassifying-aeds-costs-expected-to-rise.
Class III device.
By the end of the year, the FDA is expecting to
3. Lazar, RA. Data and public health considerations
reclassify AEDs as devices that will need extensive,
do not support AED reclassification: Public
and expensive, pre-market testing.
Comment [Internet]. Readiness Systems, LLC;
79
6. Eisenberg M, Rea T. Accelerating progress in
Articles:
community resuscitation. Heart. Epub 2014 Feb 10.
1. Laurent I, Adrie C, Vinsonneau, Cariou A, Chiche
JD, Ohanessian A, Spaulding C, Carli P, Dhainaut JF,
An editorial arguing for the relaxation of regulation
Monchi M. High volume hemofiltration after out of
in order to facilitate widespread dissemination of
hospital cardiac arrest: a randomized study. J Am
AEDs into homes and businesses.
Coll Cardiol. 2005;46:432-7.
5. Hemofiltration for post-resuscitation
therapy
This trial randomized 61 patients admitted to
hospital after out-of-hospital cardiac arrest due
to ventricular fibrillation or asystole to one of 3
Description:
Hemofiltration is designed to remove toxins from
the blood and there has been limited use in treating
humans post cardiac arrest
Assessment:
Hard to assess as the therapy is currently
considered experimental.
Impact:
Potentially beneficial in a small group of patients.
Implementation:
Costly and complicated to achieve in a timely
fashion.
treatment strategies: high volume hemofiltration
(HF), HF with hypothermia, or control. Compared
to standard care (controls), recipients of HF with
or without hypothermia had significantly better
survival at 6 months.
2. Karnad V. Continuous renal replacement
therapy may aid recovery after cardiac arrest.
Resuscitation. 2006;68:417-9.
Detailed case report of a patient who sustained a
cardiac arrest due to ventricular fibrillation with
severely impaired neurological status, who made
a rapid and complete recovery after institution of
hemofiltration therapy.
Science:
One randomized clinical trial from France showed
improved survival and neurological outcome in
patients treated with hemofiltration compared to
patients with standard care.
80
6. ECMO for cardiac arrest
Impact:
Probably limited to a few conditions (such as
Description:
Extracorporeal membrane oxygenation (ECMO) also
refractory VF) with application in tertiary care
institutions.
called extracorporeal life support (ECLS) or ECPR
(extracorporeal CPR) is a technique to to provide
Implementation:
cardiac and respiratory support by oxygenating the
Definitely not yet ready for wide-spread use. Many
blood outside the body and returning it to the body.
more case series need to be done to define the
There are several types of ECMO depending on
benefits and limitations of ECMO.
whether the heart can adequately maintain blood
pressure. Cannulation can occur in the femoral
Science:
artery and femoral vein or femoral vein and internal
Use of ECMO post cardiac arrest is very “heroic” at
jugular vein or right atrium and ascending aorta
the moment but several case series suggest it may
(the latter is used for the most serious conditions).
play a role in limited circumstances.
The major clinical use of ECMO is in respiratory
failure, cardiogenic shock and as bridge therapy
for cardiac transplantation and placement of a
ventricular assist device.
Articles:
1. Stub D, Byrne M, Pellegrino V, Kaye DM.
Extracorporeal membrane oxygenation to support
cardiopulmonary resuscitation in a sheep model of
Assessment:
refractory ischaemic cardiac arrest. Heart Lung Circ.
ECMO has largely been a hosptial and ICU-based
2013;22:421-7.
procedure applied to critically ill patients. Most
of the experience comes from pediatric patients.
ECPR increases return of circulation and coronary
It may eventually play a role for cardiac arrest
perfusion pressure in a sheep model of ischaemic
patients who have refractory VF. At this time ECMO
VF arrest. The authors support the development of
is a hospital-based procedure though one might
a pilot trial into the effectiveness and feasibility of
envision a prehospital ECMO-type device in the
ECPR in the clinical setting.
future.
2. Chen YS, Yu HY, Huang SC, Lin JW, Chi NH,
Wang CH, Wang SS, Lin FY, Ko WJ. Extracorporeal
membrane oxygenation support can extend the
81
duration of cardiopulmonary resuscitation. Crit Care
ECPR initiation. Future studies might focus on the
Med. 2008;36:2529-35.
indications for ECPR, which should maximize the
survival potential after ECPR while reducing the
Assisted circulation might extend the presently
overuse of this resource-intensive facility.” - from
accepted duration of cardiopulmonary resuscitation
abstract
in adult in-hospital cardiopulmonary resuscitation
patients.
3. Kagawa E, Inoue I, Kawagoe T, Ishihara M,
Shimatani Y, Kurisu S, Nakama Y, Dai K, Takayuki O,
Ikenaga H, Morimoto Y, Ejiri K, Oda N. Assessment
of outcomes and differences between in- and outof-hospital cardiac arrest patients treated with
cardiopulmonary resuscitation using extracorporeal
life support. Resuscitation. 2010;81:968-73.
CPR with ECLS led to more favourable patient
outcomes after IHCA compared with OHCA in our
patient group. The difference in outcomes for ECLS
after IHCA and OHCA disappeared after adjusting
for patient factors and the time delay in starting
ECLS. - from the abstract
4. Wang CH, Chen YS, Ma MH. Extracorporeal life
support. Curr Opin Crit Care. 2013;19:202-7.
“In this review, survival after ECPR was generally
best after pediatric IHCA (38-57%), followed by
adult IHCA (34-46%) and then adult OHCA (436%). …[there appears to be] no consensus on
the optimal conventional CPR duration before
7. Detect blood flow during cardiac arrest
Description:
Chest compressions are delivered in order to
provide perfusion when the heart is not pumping
effectively. Clinical outcomes have been shown to
clearly improve survival when high quality CPR is
delivered. The actual determination of how effective
chest compressions are in an individual patient
has been difficult to assess accurately. A method
which would provide a quantitative indication of
the degree of blood flow and tissue perfusion being
provided by CPR would give rescuers the ability to
tailor CPR delivery to provide the best perfusion
possible for each patient. When available in realtime, a measure of perfusion would allow for the
adjustment of chest compression rate, depth, duty
cycle, force and other factors so that perfusion
could be optimized. If one considers “perfusion” to
be composed of two parts, blood flow and oxygen
delivery, then the ability to determine the presence
of flow and oxygen saturation together would be
optimum. This knowledge could also guide the
delivery of ventilations and the need for additional
airway interventions if the blood flow were known
82
to be adequate but the oxygenation was not. To be
methods are calibrated in experimental studies
useful in the field these methods should be easy to
where invasive monitoring can be performed to
apply and noninvasive.
verify the parameters producing the best blood
flow and these can be applied in the field where
Assessment:
A blood flow detector to help guide CPR would
advance the clinical practice of resuscitation. It
would allow the delivery of chest compressions to
be adjusted for the individual patient to provide
increased tissue perfusion. The methods exist
but must be further developed so that they are
robust enough to be applied where the cardiac
arrests occur, the field. These methods also must
be inexpensive and relatively simple to apply. In
all probability there will be incremental advances
until a clear leader emerges from the candidate
the improvement in survival is measured. New
methods under development which would allow
direct determination of actual tissue perfusion in
the ‘microcirculation’ include biophotonic methods.
Other methods to estimate perfusion based
on ultrasound have also been proposed. These
measure flow in the larger vessels and several
have the potential to indicate flow to the brain.
Transcranial doppler ultrasound has been proposed
as a method that could be adapted for use in the
field. Finally, one may find the use of imaging
processing methods to qualitatively determine
methods.
the presence of a pulse video imaging which
Impact:
cameras. These demonstrate the feasibility of using
Potentially this could improve resuscitation
outcomes by guiding CPR and therapy.
Implementation:
Awaits further development.
Science:
Current methods to optimize blood flow during
chest compressions are based primarily on the
use of feedback to the rescuer using a device
under the rescuer’s hands that determines force
and rate and automated devices. These practical
has now become mainstream in cell phones and
commonly available technologies and applying them
to the cardiac arrest situation to our advantage.
Science:
Some potentially useful technologies include
plethysmography and ultrasound.
Articles:
1. Leahy MJ, Enfield JG, Clancy NT, ODoherty
J,McNamara P, Nilsson GE. Biophotonic methods in
microcirculation imaging; Med Laser Application.
2007;22:105-26.
83
An overview of the various technical methods to
visualize the microcirculation with light and doppler.
Side stream dark field imaging is used during
cardiac arrest and resuscitation of a 29 year old
2. Millet C, Roustit M, Blaise S, Cracowski JL.
victim of drowning.
Comparison between laser speckle contrast imaging
and laser Doppler imaging to assess skin blood flow
5. Fries M, Tang W, Chang Y, Wang J, Castillo
in humans; Microvasc Res. 2011;82:147-51.
C, Weil MH. Microvascular blood flow during
cardiopulmonary resuscitation is predictive of
A demonstration of how well these techniques work
outcome. Resuscitation. 2006;71:248-53.
in assessing the microcirculation.
Uses the side stream method in sublingual
3. Elbers WG, Wijbenga J, Solinger F, Yilmaz
measurements with a swine model and full
A, van Iterson M, van Dongen E, Ince C. Direct
instrumentation for experimental validation of this
observation of the human microcirculation
technique.
during cardiopulmonary bypass: effects of
pulsatile perfusion. J Cardiothorac Vasc Anesth.
2011;25:250-5.
Examines the use of side stream dark field imaging
during bypass and a comparison of pulsatile and
non-pulsatile flow and the effect on tissue perfusion
in human subjects.
4. Elbers PWG, Craenen AJ, Driessen A, Stehouwer
MC, Munsterman L, Prins M, van Iterson M, Bruins
P, Ince C. Imaging the human microcirculation
during cardiopulmonary resuscitation in a
hypothermic victim of submersion trauma.
Resuscitation. 2010;81:123-5.
84
6. Weil MH. Microvascular flow during mechanical
9. Imberti R, Bellinzona G, Riccardi F, Pagani
cardiopulmonary resuscitation. Resuscitation.
M, Langer M. Cerbral perfusion pressure and
2010;81:5.
cerebral tissue oxygen tension in a patient during
cardiopulmonary resuscitation. Intensive Care Med.
This is an editorial on the subject of microvascular
2003;29:1016-9.
perfusion measurements.
Presentation of a case in which a patient was
7. Petrovic T, Gamand P, Tazarourte K, Catineau
being monitored with cerebral tissue oxygen
J, Lapostolle F. Letter to the Editor: Feasibility of
tension measurements during a cardiac arrest.
transcranial Doppler ultrasound examination out-of-
Cerebral perfusion pressure is compared to tissue
hospital. Resuscitation. 2010;81:126-7.
oxygenation.
Presents the thesis that transcranial Doppler
8. Ischemic post-conditioning therapy
imaging could be extended to the prehospital
setting and should be considered.
8. Wu HY, Rubinstein M, Shih E, Guttag J, Durand
F, Freeman W. Eulerian video magnification for
revealing subtle changes in the world [Internet].
2012 [cited 2014 Feb 28]. Available from: http://
people.csail.mit.edu/mrub/vidmag/.
This site has the reference material with
appropriate links along with several very good
videos showing the pulse brought out in the human
face and arm, etc. using special imaging techniques
called “Eulerian Video Magnification”. These are
software adaptations that allow one to see changes
that are below our normal levels of perception.
Description:
Ischemic Post-ischemic conditioning (IPC) attempts
to reduce cellular injury resulting from the reflow of
blood after return of circulation. The strategy is to
perform CPR for a brief period and then pause for
a brief period, such as 15 seconds of CPR followed
by 5 seconds without CPR. Presumably this will
condition mitochondria within the cells and thus
minimize the level of damage. This is experimental.
Assessment:
This intriguing therapy has been demonstrated
in animal models but benefit in humans is to be
determined.
85
Impact:
but manifested better left ventricular function and
Could be large if proven effective in human cardiac
neurological status.
arrest.
2. Vinten-Johansen J, Zhao Z, Zatta AJ, Kin
Implementation:
H, Halkos ME, Kerendi F. Postconditioning: a
It might be relatively easy to accomplish with a
new link in nature’s armor against myocardial
change in the protocol for delivery of CPR.
ischemia-reperfusion injury. Basic Res Cardiol.
2005;100:295-310.
Science:
All data come from animal studies.
Articles:
1. Segal N, Matsuura T, Caldwell E, Sarraf M,
McKnite S, Zviman M, Aufderheide TP, Halperin HR,
Lurie KG, Yannopoulos D. Ischemic postconditioning
at the initiation of cardiopulmonary resuscitation
facilitates functional cardiac and cerebral recovery
after prolonged untreated ventricular fibrillation.
Resuscitation. 2012;83:1397-403.
This was a prospective study of pigs with
protracted (15 minutes) untreated ventricular
fibrillation who were randomized to receive
standard CPR as compared with 4 controlled
20 second pauses during the first 3 minutes
of CPR, followed by standard care measures in
both groups. As compared with standard CPR,
recipients of ischemic postconditioning (via
“controlled interrupted CPR”) had a comparable
return of circulation and 24 hour survival,
This review article describes the pathophysiology of
reperfusion injury and how it might be modified by
post-ischemic conditioning.
3. Yannopoulos D, Segal N, Matsuura T,
Sarraf M, Thorsgard M, Caldwell E, Rees J,
McKnite S, Santacruz K, Lurie KG. Ischemic
postconditioning and vasodilator therapy during
standard cardiopulmonary resuscitation to
reduce cardiac and brain injury after prolonged
untreated ventricular fibrillation. Resuscitation.
2013;84:1143-9.
This was a prospective study of pigs with
protracted (15 minutes) untreated ventricular
fibrillation who were randomized to receive
standard CPR with and without concomitant
vasodilator therapy, as compared to postischemic conditioning (performed as described in
reference #1 above) with and without concomitant
vasodilator therapy, followed by standard care
measures in all treatment groups. Compared
86
with standard CPR, recipients of postischemic
This is a position paper describing some of the
conditioning and recipients of standard CPR with
potential mechanisms accounting for the effects of
vasodilatory therapy had better left ventricular
postischemic conditioning.
function after resuscitation, but only postischemic
conditioning resulted in improved 48 hours survival
6. Halestrap AP. A pore way to die: the
and better neurological outcome.
role of mitochondria in reperfusion injury
and cardioprotection. Biochem Soc Trans.
4. Segal N, Matsuura T, Caldwell E, Sarraf M,
2010;38:841-60.
McKnite S, Zviman M, Aufderheide TP, Halperin HR,
Lurie KG, Yannopoulos D. Ischemic postconditioning
This review paper describes the role of mitochondria
at the initiation of cardiopulmonary resuscitation
and the mitochondrial permeability transition pore
facilitates functional cardiac and cerebral recovery
(MPTP) in reperfusion injury and cardioprotection.
after prolonged untreated ventricular fibrillation.
Resuscitation. 2012;83:1397-403
9. Point of care testing
IPC and cardiovascular vasodilation therapy during
Description:
standard CPR improved post-resuscitation LVEF
but only IPC was independently neuroprotective
and improved 48 hour survival after 15 minutes of
untreated cardiac arrest in pigs.
5. Ovize M, Baxter GF, DeLisa F, Ferdinandy P,
Garcia-Dorado D, Hausenloy DJ, Heusch G, VintenJohansen J, Yellon DM, Schulz R; Working Group
of Cellular Biology of Heart of European Society of
Cardiology. Postconditioning and protection from
reperfusion injury: Where do we stand? Position
paper from the Working Group of Cellular Biology
of the Heart of the European Society of Cardiology.
Cardiovasc Res. 2010;87:406-23.
Point of care testing refers to on-scene
measurement of blood chemistries. The technology
for measuring chemistries from micro drops of
blood and having results in a few seconds or
minutes exists currently. A consumer example
of point of care testing is measurement of blood
glucose. Candidate chemistries would be blood
gases including pH and lactate levels.
Assessment:
Knowledge of selected blood chemistries could
conceivably help to guide a resuscitation and inform
rational post-resuscitation therapy. There have
not been convincing studies yet to identify which
chemistries would have utility.
87
Impact:
Lactate measurement is a valuable tool to
This technique could have a modest benefit by
determine metabolic acidosis during CPR and
intelligently guiding therapy.
may be able to replace blood gas analysis in this
situation.
Implementation:
For now pilot studies might define blood chemistries
3. Müllner M, Sterz F, Domanovits H, Behringer W,
with clinical utility.
Binder M, Laggner AN. The association between
blood lactate concentration on admission, duration
Science:
Point of care testing exists in many clinical settings
(emergency departments, ICUs, out-patient clinics,
developing country health settings).
Articles:
1. Ahn S, Kim WY, Sohn CH, Seo DW, Kim W, Lim
KS. Potassium values in cardiac arrest patients
measured with a point-of-care blood gas analyzer.
Resuscitation. 2011;82:25-6.
Potassium levels are critical to proper cardiac
conduction. Too high levels can lead to cardiac
arrest and this is a common reason for arrest in
dialysis patients.
2. Prause G, Ratzenhofer-Comenda B, SmolleJüttner F, Heydar-Fadai J, Wildner G, Spernbauer
P, Smolle J, Hetz H. Comparison of lactate or
BE during out-of-hospital cardiac arrest to
determine metabolic acidosis. Resuscitation.
2001;51:297-300.
of cardiac arrest, and functional neurological
recovery in patients resuscitated from ventricular
fibrillation. Intensive Care Med. 1997;23:1138-43.
“The arterial admission lactate concentration after
out-of-hospital ventricular fibrillation cardiac arrest
is a weak measure of the duration of ischemia. High
admission lactate levels are associated with severe
neurological impairment. However, this parameter
has poor prognostic value for individual estimation
of the severity of subsequent functional neurological
impairment.” - from abstract
4. Testa A, Cibinel GA, Portale G, Forte P, Giannuzzi
R, Pignataro G, Silveri NG. The proposal of an
integrated ultrasonographic approach into the ALS
algorithm for cardiac arrest: the PEA protocol. Eur
Rev Med Pharmacol Sci. 2010;14:77-88.
“This article deals with the application of clinical
ultrasonography (US) in resuscitation, presenting
a simple codified US protocol usable during CPR
to recognize reversible causes of cardiac arrest.
88
Clinical US, using a well codified protocol, could
1.838-25.827; OR 6.89).” - from abstract
effectively help to identify reversible causes in CA,
even improving patients outcome.” - from abstract
7. Soremekun OA, Datner EM, Banh S, Becker
LB, Pines JM. Utility of point-of-care testing in ED
5. Halpern MT, Palmer CS, Simpson KN, Chesley FD,
triage. Am J Emerg Med. 2013;31:291-6.
Luce BR, Suyderhoud JP, Neibauer BV, Estafanous
FG. The economic and clinical efficiency of point-
Potential benefit of point of care testing for critically
of-care testing for critically ill patients: a decision-
ill emergency departmnent testing is described.
analysis model. Am J Med Qual. 1998;13:3-12.
“The positive clinical impact of using POC testing
was consistently associated with a positive
economic impact. POC blood gas analysis may be
associated with decreased incidence of adverse
clinical events or earlier detection of such events,
resulting in significant cost savings.” - from abstract
6. Takaki S, Kamiya Y, Tahara Y, Tou M, Shimoyama
A, Iwashita M. Blood pH is a useful indicator for
initiation of therapeutic hypothermia in the early
phase of resuscitation after comatose cardiac
arrest: a retrospective study. J Emerg Med.
2013;45:57-64.
“Multivariate logistic analysis showed that initial
heart rhythm and pH levels were significantly
higher in the GR [good recovery] group than in the
non-GR group (ventricular tachycardia/VF rate:
p = 0.055, 95% confidence interval [CI] 0.76884.272, odds ratio [OR] 8.047; pH: 7.155 ± 0.139
vs. 6.895 ± 0.100, respectively, p < 0.001, 95% CI
10. Develop a cardiac arrest detector
Description:
Approximately 50% of all cardiac arrests are
unwitnessed. Though there may be someone in
the immediate vicinity, the actual collapse is not
seen or heard and thus the chances of a successful
resuscitation fall dramatically. If a person at
higher risk of cardiac arrest could wear (or have
implanted) a cardiac arrest detector, then alarms
could summon nearby help.
Assessment:
Potentially large, though one would likely have
to determine who is at risk (currently not easy
to do other than for some higher risk groups, for
example, persons with coronary artery disease).
Any wearable device would have challenges of
all wearable items (remembering to put it on,
tolerating it, battery replacements, etc.). Then
there is the anticipatory anxiety that might be
associated with such a device though this does not
89
appear to be a large concern among persons with
are so poorly understood. Only a small minority
implantable cardiovertor defibrillators.
of patients have clearly defined causes for VF.
These include patients with conduction defects
Impact:
(such as prolonged Q-T syndrome) and structural
The impact is difficult to speculate.
abnormalities in the heart (such as hypertrophic
Implementation:
VF, these patients are candidates for implantable
The technology for such a device does not yet exist.
Science:
The technology for such a device does not yet exist.
Summary:
The challenge is to make such a detector totally
accurate. False positives would quickly make the
detector’s alarms ignored - not unlike the boy who
cried “wolf” too often.
Articles:
Appropriate articles were not found.
cardiomyopathy). Because of the increased risk of
cardiovertor defibrillators (ICD). But for the vast
majority of VF patients the specific triggering
event is poorly understood. A majority of patients
(perhaps as many as 80-90%) who have VF SCA
have underlying ischemic heart disease (IHD). It
is felt that an obstructed coronary artery leading to
ST-elevation myocardial infarction (STEMI) leads to
toxins or biochemical changes that in turn trigger
VF. This may account for 20-25% of VF events.
For other patients with ischemic heart disease it
is believed that an episode of ischemia (with or
without symptoms) may trigger VF. This likely
accounts for 40-50% of VF events.
In the past forty years the incidence of VF has
11. Prevent the onset of ventricular
declined and this decline parallels the decline in
fibrillation
the incidence of ischemic heart disease. Thus
until the trigger(s) of VF are understood the best
Description:
The concept of prevention is very straightforward.
The best way to reduce death from SCA is to avoid
the onset of VF. A medication or vaccination could
conceivably prevent the onset of VF. Easier said
than done especially since the trigger(s) of VF
preventive strategy is to continue efforts to reduce
the incidence of ischemic heart disease and assume
such a decline will lead to a decline in VF. It is also
possible that the incidence of IHD may increase in
decades ahead due to dramatic recent increases in
obesity and type II diabetes. Diabetes is a strong
90
risk factor for the development of IHD.
Seattle over a period of two decades, during which
Even though the triggers of VF are not understood
time the annual rate of VF declined from 0.85 to
it seems likely that the incidence of VF will fall as
0.38 per 1000 persons.
the incidence of IHD falls.
2. Bunch TJ, White RD. Trends in treated
Impact:
The imact would be huge but it is mostly “a wish”
ventricular fibrillation in out of hospital cardiac
arrest: Ischemic compared to non-ischemic heart
at this time.
disease. Resuscitation. 2005;67:51-4.
Implementation:
This observational study compared the incidence
We are likely a long way from realizing this
strategy.
Science:
There is much speculation at this time.
Summary:
There are no data pointing toward specific
prevention of VF. It may be a long time until the
triggers of VF are precisely identified and thus a
of out-of-hospital ventricular fibrillation (VF)
in Rochester, MN in patients with and without
ischemic heart disease. While the incidence of VF
associated with ischemic heart disease declined
over the study period, this was not the case among
patients without ischemic heart disease, in whom
the incidence of VF increased slightly. These
findings were taken to suggest that the decline in
VF may be attributable to the impact of treatment
strategies directed at coronary artery disease.
specific preventive strategy seems remote.
Articles:
1. Cobb LA, Fahrenbruch CE, Olsufka M, Copass
MK. Changing incidence of out of hospital
ventricular fibrillation, 1980-2000. JAMA.
2002;288:3008-13.
This observational study evaluated the incidence
of out-of-hospital ventricular fibrillation (VF) in
91
Summary
Two interventions are unequivocally and strongly related to surviving SCA. The first intervention is CPR
and the sooner it is started the higher the likelihood of survival. For all practical purposes the only way
to achieve rapid initiation of CPR is for a bystander to start it. Telecommunicators have the opportunity to
facilitate bystander CPR for most cardiac arrests. The challenge is how best to train telecommunicators
and how to institute ongoing QI programs. The quality of CPR also appears to be related to survival.
High-performance CPR, with its emphasis on letter-perfect CPR and minimal interruptions in chest
compressions, appears to improve survival. The challenge is how to insure that all EMS personnel are
trained in this procedure. The second intervention is rapid defibrillation. As with CPR the sooner a
defibrillatory shock can be provided the higher the likelihood of survival. Efforts to disseminate automatic
external defibrillators (AEDs) into homes and more public places will lead to more cardiac arrests receiving
defibrillation prior to EMS arrival.
Interventions with insufficient scientific support are advanced life support skills such as medications. The
issue of antiarrhythmic medication benefit is currently being evaluated by the Resuscitation Outcomes
Consortium. There are also preliminary plans to test the benefit of epinephrine for cardiac arrest. An
intervention whose role is unclear is hospital hypothermia. (A recent study suggests mild cooling to 36
degrees C. - and prevention of fever - may define prudent clinical practice until the issue of cooling is
definitively clarified.)
Until (and if) specific prevention of VF becomes a reality, the primary and secondary prevention of
coronary artery disease will likely lower the incidence of VF.
92
Appendix
Articles describing the demographics and incidence of cardiac arrest.
1. Rea TD, Eisenberg MS, Sinibaldi G, White RD. Incidence of EMS-treated out-of-hospital cardiac arrest in
the United States. Resuscitation. 2004;63:17-24.
2. Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, Rea T, Lowe R, Brown T, Dreyer
J, Davis D, Idris A, Stiell I; Resuscitation Outcomes Consortium Investigators. Regional variation in out-ofhospital cardiac arrest incidence and outcome. JAMA. 2008;300:1423-31.
3. Atwood C, Eisenberg MS, Herlitz J, Rea TD. Incidence of EMS-treated out-of-hospital cardiac arrest in
Europe. Resuscitation. 2005;67:75-80.
4. Meyer L, Stubbs B, Fahrenbruch C, Maeda C, Harmon K, Eisenberg M, Drezner J. Incidence, causes,
and survival trends from cardiovascular-related sudden cardiac arrest in children and young adults 0 to 35
years of age: a 30-year review. Circulation. 2012;126:1363-72.
5. Vaartjes I, Hendrix A, Hertogh EM, Grobbee DE, Doevendans PA, Mosterd A, Bots ML. Sudden
death in persons younger than 40 years of age: incidence and causes. Eur J Cardiovasc Prev Rehabil.
2009;16:592-6.
6. Chugh SS, Uy-Evanado A, Teodorescu C, Reinier K, Mariani R, Gunson K, Jui J. Women have a lower
prevalence of structural heart disease as a precursor to sudden cardiac arrest: The Ore-SUDS (Oregon
Sudden Unexpected Death Study). J Am Coll Cardiol. 2009;54:2006-11.
7. Albert CM, Chae CU, Grodstein F, Rose LM, Rexrode KM, Ruskin JN, Stampfer MJ, Manson
JE. Prospective study of sudden cardiac death among women in the United States. Circulation.
2003;107:2096-101.
8. Kim C, Fahrenbruch CE, Cobb LA, Eisenberg MS. Out-of-hospital cardiac arrest in men and women.
Circulation. 2001;104:2699-703.
93
Articles about treatments and predictors of survival from cardiac arrest:
1. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest:
a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010;3:63-81.
2. Gilmore CM, Rea TD, Becker LJ, Eisenberg MS. Three-phase model of cardiac arrest: time-dependent
benefit of bystander cardiopulmonary resuscitation. Am J Cardiol. 2006;98:497-9.
3. Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating effectiveness of cardiac arrest
interventions: a logistic regression survival model. Circulation. 1997;96:3308-13.
4. Holmberg M, Holmberg S, Herlitz J. Incidence, duration and survival of ventricular fibrillation in out-ofhospital cardiac arrest patients in Sweden. Resuscitation. 2000;44:7-17.
5. Cobb LA, Fahrenbruch CE, Olsufka M, Copass MK. Changing incidence of out-of-hospital ventricular
fibrillation, 1980-2000. JAMA. 2002;288:3008-13.
6. Bunch TJ, White RD. Trends in treated ventricular fibrillation in out-of-hospital cardiac arrest: ischemic
compared to non-ischemic heart disease. Resuscitation. 2005;67:51-4.
7. Kudenchuk PJ, Redshaw JD, Stubbs BA, Fahrenbruch CE, Dumas F, Phelps R, Blackwood J, Rea TD,
Eisenberg MS. Impact of changes in resuscitation practice on survival and neurological outcome after outof-hospital cardiac arrest resulting from nonshockable arrhythmias. Circulation. 2012;125:1787-94
8. Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac
arrest: a graphic model. Ann Emerg Med. 1993;22:1625-8.
9. Eisenberg MS. Resuscitate! How Your Community Can Improve Survival From Sudden Cardiac Arrests.
2nd ed. Seattle, University of Washington Press, 2013.
94
Articles about the Utstein template for reporting cardiac arrest::
1. Cummins RO, Chamberlain DA, Abramson NS, Allen M, Baskett PJ, Becker L, Bossaert L, Delooz HH,
Dick WF, Eisenberg MS. Recommended guidelines for uniform reporting of data from out-of-hospital
cardiac arrest: the Utstein Style. A statement for health professionals from a task force of the American
Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and
the Australian Resuscitation Council. Circulation. 1991;84:960-75.
2. Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, Cassan P, Coovadia A, D'Este K, Finn J,
Halperin H, Handley A, Herlitz J, Hickey R, Idris A, Kloeck W, Larkin GL, Mancini ME, Mason P, Mears G,
Monsieurs K, Montgomery W, Morley P, Nichol G, Nolan J, Okada K, Perlman J, Shuster M, Steen PA,
Sterz F, Tibballs J, Timerman S, Truitt T, Zideman D; International Liaison Committee on Resuscitation;
American Heart Association; European Resuscitation Council; Australian Resuscitation Council; New
Zealand Resuscitation Council; Heart and Stroke Foundation of Canada; InterAmerican Heart Foundation;
Resuscitation Councils of Southern Africa; ILCOR Task Force on Cardiac Arrest and Cardiopulmonary
Resuscitation Outcomes. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and
simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals
from a task force of the International Liaison Committee on Resuscitation (American Heart Association,
European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council,
Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of
Southern Africa). Circulation. 2004;110:3385-97.
3. Castrén M, Karlsten R, Lippert F, Christensen EF, Bovim E, Kvam AM, Robertson-Steel I, Overton J,
Kraft T, Engerstrom L, Garcia-Castrill Riego L; Emergency Medical Dispatch expert group at the Utstein
Consensus Symposium 2005. Recommended guidelines for reporting on emergency medical dispatch when
conducting research in emergency medicine: the Utstein style. Resuscitation. 2008;79:193-7.
4. Zaritsky A, Nadkarni V, Hazinski MF, Foltin G, Quan L, Wright J, Fiser D, Zideman D, O'Malley P,
Chameides L. Recommended guidelines for uniform reporting of pediatric advanced life support: the
pediatric Utstein Style. A statement for healthcare professionals from a task force of the American
Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council. Writing
Group. Circulation. 1995;92:2006-20.
95
5. Rea TD, Cook AJ, Stiell IG, Powell J, Bigham B, Callaway CW, Chugh S, Aufderheide TP, Morrison L,
Terndrup TE, Beaudoin T, Wittwer L, Davis D, Idris A, Nichol G; Resuscitation Outcomes Consortium
Investigators. Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements.
Ann Emerg Med. 2010;55:249-57.
96
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Utstein Survival Report
All Agencies/National Data
Service Date: From 1/1/12 Through 12/31/12
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*Only data from the previous calendar year is fully audited. Data from the current calendar year is dynamic.
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April 11, 2013
©2000-2013 Sansio. Sansio - myCARES™
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