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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 - Utstein Survival Report All Agencies/National Data Service Date: From 1/1/12 Through 12/31/12 - *Only data from the previous calendar year is fully audited. Data from the current calendar year is dynamic. - April 11, 2013 ©2000-2013 Sansio. Sansio - myCARES™ 1 of 3