Download Medic One/Emergency Medical Services

CBT Instructors Workshop
Today’s Topics
1
State of King County EMS
2
CPR: Then and Now
3
New CPR Guidelines
4
ROC Study
1
State of King County EMS
2006
Mickey Eisenberg, MD, PhD
Medical Program Director
1
What We Have Accomplished?
1.85
170
1.80
150
1.75
130
1.70
110
1.65
90
1.60
1.55
70
1.50
50
2001
2002
Population
2003
2004
2005
BLS Call Volume
BLS Call Volume (thousands)
Population (millions)
Population & BLS Call Volume
1
Time of Response
Number of Responses by Hour of the Day
10000
9000
ALS Responses
8000
BLS Responses
7000
6000
5000
4000
3000
2000
1000
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
0
Hour of the Day
1
BLS
Number of Responses:
Avg. Response Times:
162,510
Total
Unit
Minutes
6.0
4.7
6 Minutes or less
72.2%
84.1%
8 Minutes or less
10 Minutes or less
12 Minutes or less
14 Minutes or less
Cancelled Enroute Calls
2.2%
04
510 9
-1
15 4
-1
20 9
-2
25 4
-2
30 9
-3
35 4
-3
40 9
-4
45 4
-4
50 9
-5
55 4
-5
60 9
-6
65 4
-6
70 9
-7
75 4
-7
80 9
-8
85 4
-8
90 9
95 -94
-9
9+
1
Age Distribution
ALS & EMS Age Distribution
12000
ALS Responses
10000
BLS Responses
8000
6000
4000
2000
0
Age
1
Responses by Type
ALS
BLS
Cardiac
10,846 (26%)
12,823
(10%)
Respiratory
6,144 (15%)
11,875
(9%)
Neurological
5,942 (14%)
18,406 (14%)
Trauma
4,333 (10%)
36,855 (29%)
Abdominal/Genito-Urinary
Metabolic/Endocrine
Alcohol/Drug
Psychiatric
Anaphylaxis/Allergy
Obstetric/Gynecological
2,304 (6%)
2,105 (5%)
1,607 (4%)
1,403 (3%)
426 (1%)
420 (1%)
9,132
3,719
5410
6598
1774
1038
Other Illness
6,162 (15%)
21,480 (17%)
41,692
129,110
Total
(7%)
(3%)
(4%)
(5%)
(1%)
(1%)
1
Location
ALS
BLS
Home/Residence
23,590 (58%)
72,844 (53%)
Nursing Home/Adult
Family Home
3,476
(9%)
8,919
(6%)
Clinic/MD Office
2,007
(5%)
3,099
(2%)
Other/Unknown
Location
11,680 (29%)
54,397 (39%)
40,753
139,259
Total
1
Cardiac Arrest
Total number of cardiac arrests for all
causes with resuscitation attempted:
YEAR
#
2001
1141
2002
1147
2003
1093
2004
1087
2005
1124
1
Survival
50
45
45
Percent Survival
40
35
37
36
30
34
31
25
20
15
10
5
0
2001
2002
2003
Ye ar
2004
2005
1
Past Year
•
•
•
•
Infectious Disease Plan
ROC infrastructure established
CPR/Defibrillation protocol changed
EMT naloxone
1
EMT Naloxone
Study of potential benefit of EMT naloxone for
narcotic overdose:
• 164 patients received naloxone for OD in one
year.
• Respiratory rate < 10 in 48%.
• Good response in 73%.
• Uneven distribution among departments.
• Agitation/combativeness in 15%, emesis in
6%.
1
Past Year
•
•
•
•
•
Infectious Disease Plan
ROC infrastructure established
CPR/Defibrillation protocol continuation
EMT naloxone
SPHERE pilot
1
JEMS: June 2006
1
SPHERE Pilot
• South King Fire and Rescue, Kent, Port of
Seattle, Auburn
• Comparison of alert (given by EMTs) versus
letter sent by medical director
• Follow-up phone call
1
SPHERE Pilot
For more information on
high blood pressure, you
can call the American
Heart
Association
High
Blood
Pressure
Alert
1-800-AHA-USA-1
(1-800-242-8721)
or go online to
www.americanheart.org
The City of Kent F ire Department took your blood pressure during
your medical emergency. Your blood pressure was very high.
Date: ___________________________
Blood Pressure Categories
EMT: ___________________________
S ystolic
Sy stolic : __________
FOLD
Your blood pressure:
Diastolic: _________
High blood pressure can lead to lifethreatening disease such as heart
disease or stroke or kidney failure.
There are effective treatments for
lowering high blood pressure. You need
to discuss this with a doctor.
Diastolic
Hy pertension
Stage 2
100
160
140
120
Hy pertension
Stage 1
Prehy pertension
90
80
Normal
We recommend that you contact a doctor to have your blood pressure checked
again as soon as possible. We may call you in a week or two to find out how you are doing.
1
SPHERE Pilot
Patient Characteristics
Patients identified for the alert pilot had
an average systolic blood pressure of
175, and an average diastolic blood
pressure of 94.
1
SPHERE Pilot
Patient Comments
• One patient noted that she “absolutely loved”
the firefighters.
• Another patient appreciated being told about
her blood pressure and said that it was
“valuable information” for those who have
elevated BP and don’t know it.
• Another patient commented on the firefighters’
“excellent job.”
1
SPHERE Pilot
Preliminary Findings
• 65% of patients interviewed said the firefighter
influenced them to see a doctor.
• 68% of patients interviewed said the firefighter
influenced them to get their blood pressure
rechecked.
• 94% of patients interviewed were pleased that
the firefighter told them their blood pressure
was elevated.
• Alert seemed to have more influence compared
to letter.
1
New Projects for 2007
SPHERE (Supporting Public Health with Emergency
Responders)
• Expand to entire county.
• Use of routinely collected information to give
useful health information to patients
• Duty to inform patients
• Hypertension and diabetes
1
SPHERE: Standard of Care in King
County for 2007
Alerts and after-care instructions:
• High blood pressure alert
• High blood sugar alert
• Low blood sugar after-care instruction
1
High Blood Pressure Alert
For more information on
high blood pressure, you
can call the American
Heart
Association
High
Blood
Pressure
Alert
1-800-AHA-USA-1
(1-800-242-8721)
or go online to
www.americanheart.org
The City of Kent F ire Department took your blood pressure during
your medical emergency. Your blood pressure was very high.
Date: ___________________________
Blood Pressure Categories
EMT: ___________________________
S ystolic
Your blood pressure:
Sy stolic : __________
FOLD
Eligible patients:
• Systolic BP > 160 or
• Diastolic BP > 100
Not eligible:
• Paramedic transported
patients
• Nursing home patients
160
Diastolic: _________
Documentation is mandatory.
High blood pressure can lead to lifethreatening disease such as heart
disease or stroke or kidney failure.
There are effective treatments for
lowering high blood pressure. You need
to discuss this with a doctor.
140
120
Diastolic
Hy pertension
Stage 2
100
Hy pertension
Stage 1
Prehy pertension
90
80
Normal
We recommend that you contact a doctor to have your blood pressure checked
again as soon as possible. We may call you in a week or two to find out how you are doing.
1
High Blood Sugar Alert
Eligible patients:
• Diabetic: BS > 300
• Non-diabetic: BS >175
Not eligible:
• Paramedic transported
patients
• Nursing home patients
Documentation is mandatory.
For more information
on high blood sugar,
you can call the
American Diabetes
Association
1-800-DIABETES
(1-800-342-2383)
or go online to
www.diabetes.org
High
Blood
Sugar
Alert
1
Low Blood Sugar
After-Care Instructions
Eligible patients:
• Patients on insulin
• Low blood sugar
• Respond fully to
therapy
If you have any comments or
questions, please call your
local Fire Department during
normal business hours.
Low
Blood
Sugar
For more information
on low blood sugar,
you can call the
American
Diabetes
Association
After Care
Instructions
1-800-DIABETES
(1-800-342-2383)
or go online to
www.diabetes.org
Date: ___________________
EMT:____________________
Your EMS Team measured your blood sugar during your medical emergency.
Prior to treatment, your blood sugar level was _________ at _________ AM/PM.
Documentation is mandatory.
Your hypoglycemic episode was
treated by the following method:
If you are choosing to stay
at home:
□ No Treatment
 Eat a FULL MEAL NOW.
 Contact your doctor before you
The EMTs gave no immediate treatment
because_________________________
After administration of glucose and/or
prior to the departure of the EMS
Team, your blood sugar level was
_________ at _________ AM/PM.
For follow-up purposes, this information
may be shared wit h your priv ate doctor.
FOLD
□ Oral Glucose _______ gm
□ Other ____________________
take your next insulin dose. If you
are unable to contact your doctor,
reduce your next insulin dose by
25% . Keep trying to contact
your doctor.
 Check your blood sugar
frequently for the next several
hours.
 DO NOT: stay alone or drive/
operate dangerous machinery for
the next six (6) hours
 If your condition worsens or initial
signs and symptoms return, CALL
911 IMMEDIATELY!
1
2007 EMT Evaluations Underway
• Study of glucagon for hypoglycemia
• Study of left-at-scene patients following
treatment for hypoglycemia
1
Possible Future EMT Evaluations?
• EMS active screening for type II diabetes?
• Consider aspirin for acute coronary
syndrome?
• SPHERE – How to achieve follow-up?
 Pilot in Renton, Bellevue, Shoreline
• SPHERE – Pilot to compare alert versus alert
followed by reminder letter.
My Thanks
It is an honor to work with you all.
Dr. Mickey Eisenberg
Medical Director
And Finally
•
•
•
•
•
•
Questions
Suggestions
Comments
Clarifications
Opinions
Orations
2
CPR: Then and Now
Mike Helbock, M.I.C.P., NREMT-P
Manager – EMS Training and Education
Seattle/King County
It’s all about history,
learning and
and moving forward…
2
Seattle’s First Medic Unit “Moby Pig”
2
So…what’s on the ‘New to Do” list
•
•
•
•
New thoughts…. CPR compression/numbers
“Quality” of CPR (DVD-R)
NEW airway obstruction techniques
Resuscitation Outcome Consortium
2
New thoughts on the numbers
*One minute of CPR between shocks
may not be enough…
2
CPR (and all of it’s friends)
• Disappointment in the lack of increased
survival rates since the 70’s.
• Don’t be fooled…a round of CPR isn’t a
minute! (closer to 40 seconds).
• AEDs can take between 5-28 seconds to
detect a rhythm!
• Delivering up to 3 shocks can range between
39-90 seconds!
2
A Little Background
Each of the links in the chain of survival are
important for resuscitation.
9-1-1
Early
CPR
Early
Defib
Timely
ALS
2
Background, continued
Though the emphasis has been placed on early
and frequent defibrillation.
9-1-1
Early
CPR
Early
Defib
Timely
ALS
2
Background, continued
Survival
This emphasis makes sense because the chances
of survival from ventricular fibrillation decrease
5% for every minute without defibrillation.
5
10
15
Time (in minutes)
Valenzuela et al, Circulation 1997
20
2
Background, continued
With the introduction of AEDs for use by the EMTs,
response time to defibrillation decreased in King County.
10
8
Minutes
6
4
2
0
1977-81 1982-85 1986-89 1990-93 1994-97 1998-2001
Rea TD et al. Circulation
2
Background, continued
We hoped the reduction in time to defibrillation
would produce better survival results.
50
40
Survival
30
20
10
0
1977-81 1982-85 1986-89 1990-93 1994-97 1998-2001
2
Background, continued
What actually happened:
50
40
Survival
30
20
10
0
1977-81 1982-85 1986-89
1990-93 1994-97 1998-2001
2
Background, continued
So we reviewed the AHA protocol which was:
1. Determine VF.
2. Stacked shocks.
3. Pulse check after each shock.
4. 1 minute of CPR and re-analyze.
AND………
2
Background, continued
We looked more closely at the relationship
between CPR and defibrillation from a
physiological standpoint.
9-1-1
Early
CPR
Early
Defib
Timely
ALS
2
What We Found
The shock alone is not enough.
The shock can reset the heart electrically
but mechanically the heart still needs to
pump blood.
CPR before and after the shock can help
the mechanical action of the heart.
2
So…Out With the Old
The “old” AHA algorithm inadvertently increased
the amount of time without the mechanical
component of CPR.
Yet these activities were very low yield because:
• Only 10% needed a stacked shock, and
• Only 2% had a pulse with the “after shock”
pulse check.
2
In With the New
So we implemented a single shock – start CPR
algorithm in January 2005.
Eliminated stacked shocks.
Eliminated pulse check after shock.
Extended period of CPR following shock
from 1 to 2 minutes.
The goal was to increase CPR especially during
the period immediately following the shock.
2
What happened since the change?
Time to CPR after the shock decreased from
30 seconds to 6 seconds.
Duration of CPR increased from 50 seconds
to 95 seconds.
Survival to hospital discharge went from 33%
to 46%.
YEAR
96
97
98
99
00
01
02
03
04
05
%
survival
31
39
32
30
36
35
31
34
33
46
2
Summary
*More “hands on”
*Less shocks
*More focus on “Quality CPR"
*New methods of resuscitation
- cooling
- ITD
- mechanical devices
Which brings us to the question:
CAN WE DO EVEN
BETTER?
3
New CPR Guidelines
3
CPR First Study
3
CPR: Questions
• Quantity of CPR…(how much?)
• Quality of CPR…(how good?)
• Interface between the AED and defibrillation
3
New CPR Guidelines
ADULTS:
1 or 2 person CPR WITHOUT intubation
30:2
3
New CPR Guidelines
ADULTS:
1 or 2 person CPR WITHOUT intubation
30:2
Medics arrive and intubate
3
New CPR Guidelines
ADULTS:
1 or 2 person CPR WITHOUT intubation
30:2
Medics arrive and intubate
“Continuous
compressions” with
8-10 ventilations per
minute.
(1 breath/6-8 sec.)
3
New CPR Guidelines
INFANTS/
CHILDREN:
15:2
2 person CPR WITHOUT intubation (HCP)
3
New CPR Guidelines
INFANTS/
CHILDREN:
15:2
2 person CPR WITHOUT intubation (HCP)
Medics arrive and intubate
3
New CPR Guidelines
INFANTS/
CHILDREN:
15:2
2 person CPR WITHOUT intubation (HCP)
Medics arrive and intubate
“Continuous
compressions”
with 8-10
ventilations per
minute.
(1 breath/6-8 sec.)
3
CPR—Focus on Quality
Depth of
compressions
• Depth of 1 1/2–2 inches (or
more in larger people).
• Minimize interruptions in
chest compressions.
• Rotate compressors every
2–3 minutes to minimize
fatigue.
3
CPR—Focus on Quality
Depth of
compressions
Ventilations
• 30:2 prior to intubation.
• 8—10 ventilations per
minute when intubated. (1
breath/6-8 sec).
• Inspiration phase of no
more than 1 second.
3
CPR—Focus on Quality
Depth of
compressions
Ventilations
Decompression
• Complete chest recoil after
each compression.
REQUIRED!
3
CPR—Focus on Quality
Depth of
compressions
Ventilations
Decompression
Rate of
compression
• Push Hard / Push Fast
• (100/min)
Airway Obstruction
3
New Airway Guidelines
ADULTS
and
CHILD
Foreign-body airway obstruction
3
New Airway Guidelines
ADULTS
and
CHILD
Foreign-body airway obstruction
RESPONSIVE
Abdominal thrusts
(no change)
3
New Airway Guidelines
ADULTS
and
CHILD
Foreign-body airway obstruction
RESPONSIVE
UNRESPONSIVE
Abdominal thrusts
(no change)
CPR with airway check
(1 round)
3
New Airway Guidelines
INFANT
Foreign-body airway obstruction
3
New Airway Guidelines
INFANT
Foreign-body airway obstruction
RESPONSIVE
5 Backslaps/Chest Thrusts
(business as usual)
3
New Airway Guidelines
INFANT
Foreign-body airway obstruction
RESPONSIVE
UNRESPONSIVE
5 Backslaps/Chest Thrusts
(business as usual)
CPR with Airway Check
(1 round)
Rescue Breathing
3
New Airway Guidelines
ADULTS
Rescue breathing
3
New Airway Guidelines
ADULTS
Rescue breathing
10 to 12 breaths/minute
(1 breath every 5-6 seconds)
3
New Airway Guidelines
ADULTS
Rescue breathing
10 to 12 breaths/minute
(1 breath every 5-6 seconds)
Must obtain “chest rise”
3
New Airway Guidelines
CHILD /
INFANT
Rescue breathing
3
New Airway Guidelines
CHILD /
INFANT
Rescue breathing
12 to 20 breaths/minute
(1 breath every 3-5 seconds)
3
New Airway Guidelines
CHILD /
INFANT
Rescue breathing
12 to 20 breaths/minute
(1 breath every 3-5 seconds)
Must obtain “chest rise”
3
So…what are we doing about it?
•
•
•
•
•
Research, Research, Research…..
Shock early…shock often…shock a lot… is out!
Cases of VF on decline.
Conversion with 1st shock 95%.
New studies are needed to help us understand
what may be right!
The “ROC”
4
Welcome to the ROC
4
R.O.C.
• Resuscitation Outcome Consortia
• Federally Funded Data Collection Study
• Study Specific EMS Interventions
4
ROC Sites
Seattle - selected coordination site
4
ROC Sponsors
• National Institutes of Health
• Canadian Institutes of Health Research
• Defense Research & Development Canada
• American Heart Association
• Heart & Stroke - Canada
4
What is the ROC?
• Consortium of EMS providers and researchers
focused on outcomes from cardiac arrest and
trauma.
• Goal is to evaluate new approaches and
treatments.
• EMS providers will be primarily responsible for
conducting studies.
The Cardiac Arm…
4
Purpose of the Study
To determine outcomes in cardiac arrest when
comparing…
1
Difference between CPR with the
ITD and CPR with a sham valve.
2
Difference between analyze early
and analyze late protocols.
4
Analyze Early/Analyze Late
• The heart may need to be "primed"
before it can be defibrillated.
• CPR – especially chest compressions primes the heart by filling it with
oxygenated blood.
• How much priming does the heart need
before the shock?
4
Analyze Early/Analyze Late
Analyze Early:
– 1 round (30 compressions) of priming
before AED analysis
– Business as usual in Seattle/King County
Analyze Late:
– Longer period of priming before AED analysis
– 3 minutes of CPR before first analysis
4
ITD Valve
• Impedance Threshold Device
• ITD is a circulation adjunct
not a ventilation adjunct.
• Increases blood flow back to
the heart during the recoil
phase of chest compression.
4
Purpose of an ITD Valve
• Prevents air flow into
chest during recoil.
• Maximizes the vacuum
effect, pulling more blood
back to the heart.
• Which enables more
forward blood flow with
the next compression.
4
Using the ITD Valve
Can be used with:
• Bag-valve-mask
• Endotracheal tube (ETT)
ITD Valve with head strap
ITD Valve without head strap
and the
quest
continues…
Acknowledgments
•
•
•
•
•
•
Mickey Eisenberg, MD
Tom Rea, MD
Leonared Cobb, MD
Michael Copass, MD
Michele Olsufka, RN
David Carlbom, MD
•
•
•
•
•
•
Will Longstreth, MD
Steve Deem, MD
Peter Kudenchuk, MD
Charles Maynard, PhD
Billy Reuben
Medic One Foundation
Mike Helbock
206-423-4674
[email protected]