Presentation on theme: "The Arizona Cardiac Arrest Center Consortium"— Presentation transcript:
1The Arizona Cardiac Arrest Center Consortium Ben Bobrow, MDAssistant Professor, Department of Emergency Medicine, Mayo Clinic Hospital, Medical Director, Bureau of EMS & Trauma System
2PRESENTER DISCLOSURE INFORMATION Ben Bobrow, MDDisclosure InformationThe following relationships exist related to this presentation:None
3Arizona Cardiac Arrest Center Consortium Purpose:To further improve survival from out-of-hospital cardiac arrest in Arizona through implementing standardized, guideline-based post resuscitation care in our state
4Discussion GoalsReview current updates in resuscitation including importance of high quality, minimally interrupted CPRConfer the role of therapeutic hypothermia in post-cardiac arrest careDescribe the Arizona Cardiac Arrest Center model of care
6Out of Hospital Cardiac Arrest: A Common Disease ~1000 Americans will suffer OHCA today~1000 Americans will suffer OHCA tomorrow25+ will suffer OHCA during this talkHigh morbidity and mortality47% never make it to the hospital6
8Where Can EMS Make A Difference in Outcomes? CancerPneumoniaAIDSKidney DiseaseDiabetesAlzheimer’sNOT YETCardiac ArrestMajor TraumaST-Elevation MIAcute StrokePROVEN!
9Different Approach to OHCA OHCA is a major public health problemWe SHOULD maximize our resources and collaborations with the goal of improving survivalWe NEED to have a REALISTIC idea of what happens in the field where the battle is foughtEmergency medicine leaders MUST guide the community on how to bridge the gap between current knowledge and practiceAs each of us is well aware, out of hospital cardiac arrest is a major public health problem in our country.Survival rates in my community of metropolitan Phoenix, as determined by our statewide database, are dismal, averaging less than 3%.This is similar to most other large cities in our country.
10Model for OHCA Collaboration AHAMunicipal FDs Public Health Private Ambulance Local Hospitals Professional SocietiesPrivate Industry University ResearchPublic Safety OfficersPublic
1271 SHARE Participants Apache Junction FD Kingman FD River Medical AmbulanceArivaca FDLake Mohave Ranchos FDRural MetroAvondale FDLifeline AmbulanceScottsdale FDBlue Ridge FDLifestar AmbulanceSedona FDBuckeye Valley FDMaricopa FDSeligman FDChandler FDMayer FDSonoita - Elgin FDCentral Yavapai FDMesa FDSouthwest AmbulanceChino Valley FDMontezuma/Rim Rock FDSummit FDDaisy Mountain FDNogales FDSun City FDElephant Head Volunteer FDNogales Suburban FDSun City West FDEl Mirage FDNorthwest FDSun Lakes FDFlagstaff FDPage FDSurprise FDGila River Indian Community EMSPatagonia Lake State Park/Sonoita Creek State Natural Area FDTempe FDGilbert FDPatagonia Volunteer FDTolleson FDGlendale FDPayson FDTonopah Valley FDGolden Valley FDPeach Springs EMSTubac FDGoodyear FDPeoria FDTucson FDGrapevine Mesa FDPhoenix FDUnited States Border Patrol - AZGreen Valley FDPine Lake FDTusayan FDGuadalupe FDPinewood FDVerde Valley FDGuardian Medical TransportPinion Pine FDWalker FDHelmet Peak FDPMTWestern Air RescueHualapai Valley FDPrescott FDYarnell Fire DistrictPuerco Valley FDYuma FD6/24/2008
13OHCA Survival in Arizona 5040302010With so few survivors, we felt compelled to make modifications to protocol based upon current evidence and track the results closely%With so few survivors in our state, (CLICK) we felt compelled to make modifications to our protocol, based upon current evidence, and track the results closely.3Arizona2004Bobrow B et al. Circulation ; 114:II 350.
14Neurologically normal survival (%) OHCA Survival5040302010Neurologically normal survival (%)16Survival from out of hospital cardiac arrest in the United States is dismal. (CLICK)In 2004, we found comparable results in Arizona with only 3 % of ALL Out of Hospital Cardiac Arrest Victims Surviving to hospital discharge.3121Chicago ‘87Ontario ‘89LA ‘00Seattle ‘01Arizona ‘04Eckstein M et al. Annals of Emerg Med. 2005;45: Issue 5;Rea T et al. Circulation. 2003;107:
15Many Reasons for Low OHCA Survival: Poor public knowledge of cardiac arrestDelayed time to first defibrillationLow rates of bystander CPRInconsistent quality of professional CPRInconsistent post cardiac arrest careWE haven’t adequately implemented what we already know
16Standard CPR (with breaths) vs. CC alone Blood pressureTime= chest compressionBerg et al, 2001
17Standard CPR (with breaths) vs. CC alone Blood pressureTime= chest compressionBerg et al, 2001
18Hyperventilation during CPR The endAufderheide et al. Circulation 2004; 109:1960-5
19Three-Phase Model of VF 100%Myocardial ATPElectricalPhaseCirculatoryPhaseMetabolicPhase2468101214161820Arrest Time (min)Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8
20Cardiocerebral Resuscitation (CCR) Single shock ifindicated withoutpulse check orrhythm analysisSingle shock ifindicated withoutpulse check orrhythm analysisSingle shockwithout pulsecheck or rhythmanalysisEMSarrivalCCOnly•200 chestcompressions200 chestcompressions200 chestcompressions200 chestcompressionsAnalysisAnalysisAnalysisBVM or PassiveInsufflation 100% FIO2Begin IVThis is the Cardiocerebral Resuscitation protocol.Chest compression alone CPR is advocated and instructed by dispatchers.If adequate bystander chest compressions are provided, paramedics go directly to rhythm analysis and shock.If there is no bystander CPR, Paramedics administer 200 rapid forceful uninterrupted chest compressions at a rate of 100 compressions/minute allowing full chest recoil.If a shockable rhythm is present, a single shock is administered followed immediately by another 200 chest compressions prior to pulse or rhythm check.The airway is initially managed with either a BVM at a rate of 8 ventilations/minute or 100% FIO2 NRB facemask . This was left up to the paramedics discretion depending on how many providers were responding to the arrest.Paramedics administer one milligram of epinephrine Intravenously as early as possible and again with each cycle of chest compression and rhythm analysis.After 3 cycles of chest compressions and rhythm analysis, providers returned to their standard ACLS protocol consisting of endotracheal intubation and ACLS drugs.Administer 1 mgIV EpinephrineResume Standard ACLSConsider EndotrachealIntubationIf adequate bystander chest compressions are provided, EMS providersperform immediate rhythm analysis
21CCR vs. 2005 AHA Guidelines CCC-CPR for bystanders ACLS: Passive O2/BVM(protocol delayed ETT)200 CC prior to shock200 CC immediately post shockEarly epinephrine IO/IVHypothermia for all comatose30:2 CC to V(Bystander “Hands-Only CPR”)ACLS: breaths/min(timing of ETT by provider)Optional 5 cycles of 30:2 prior5 cycles of 30:2 post shockEpinephrine second cycleHypothermia for VF/VT comatose
22HypothesisOHCA victims in Arizona receiving Cardiocerebral Resuscitation would have higher survival rates than victims receiving routine Advanced Life SupportWe hypothesized that OHCA victims in Arizona receiving Cardiocerebral Resuscitation would have higher survival rates than victims receiving routine Advanced Life Support, as defined by what each EMS agency would traditionally provide.
23Methods: Data Collection and Training Utstein style databaseOctober 2004 to August 200711 of 61 (18%) elected to change to CCRTrain-the-trainer programJanuary 2005 to April 2007~3,000 EMT (B) and (P) trained(CLICK)In October 2004 we initiated an Utstein style database for the participating EMS agencies.The Cardiocerebral Resuscitation protocol was presented to EMS Medical Directors through the State EMS Council and approved as an acceptable alternate protocol.11 of the 61 EMS agencies elected to change their protocol. (CLICK)Between January 2005 and April 2007, we conducted a train-the-trainer program that consisted of a 2 hour presentation with printed material along with hands-on skills training. These trainers then trained all the providers in each agency.Approximately 3000 EMT Basics and Paramedics were trained in total.
242,284 arrests of cardiac etiology EnrollmentTotal cardiac arrestsn= 3,329171 excluded(age <18 yrs)3,158 adult874 excluded673 non-cardiac139 EMS witnessed62 missing outcomeEnrollment expanded since this abstract was first submitted.Total cardiac arrests were 3329.After excluding non-cardiac, children and arrests occurring after EMS arrival, there were 2284 adult arrests of presumed cardiac etiology.598 received Cardiocerebral Resuscitation and 1686 received Routine ALS care.2,284 arrests of cardiac etiology1,686 Routine ALS598 CCR
25Results Characteristics of OHCA Victims Characteristic CCR (n=598) ALS (n=1,686)Mean age, years (SD)** 66.1 (15.5) 67.9 (15.0)Males, % (n) 68.7 (411) 65.1 (1,098)Home location, % (n)* (455) 70.8 (1,194)Bystander CPR performed, % (n) 39.3 (235) 39.3 (663)Witnessed, % (n) 45.2 (270) 44.1 (744)Ventricular fibrillation, % (n) (195) 30.3 (510)EMS dispatch to arrival time interval, mean minutes (SD) 5.2 (2.2) 5.6 (3.2)Witnessed collapse to defibrillation time interval, mean minutes (SD) 13.7 (6.9) 13.3 (7.6)These are the characteristics of the cardiac arrest victims in our analysis:Age and location of arrest differed between the two groups with the CCR group being 1.8 years younger and having more arrests occur at home.We adjusted for these characteristics in the Logistic Regression Model.SD = Standard deviation *p<0.05 **p<0.01
26Results Survival from Out of Hospital Cardiac Arrest (36/128)CCR30252015105ALS28.1Survival to Hospital Discharge (%)These are the results,The overall survival rate to Hospital discharge for those receiving Routine ALS was 3.6% (the same 3% we found in 2004). The survival rate for those receiving Routine ALS who had a witnessed collapse and VF on EMS arrival was 10.9%.The overall survival rate for those receiving Cardiocerebral Resuscitation was 9.2% and for the subgroup with a witnessed collapse and VF on EMS arrival %.Cerebral Performance Category Score Surveys are currently underway and are a focus of our work in 2007.(38/348)(55/598)10.99.2(61/1686)3.6All cardiac arrestsWitnessed with VF
27Cardiocerebral Resuscitation Single shock ifIndicated withoutpulse check orrhythm analysisSingle shock ifIndicated withoutpulse check orrhythm analysisSingle shockwithout pulseCheck or rhythmanalysisEMSarrivalCCCOnly•200 chestcompressions200 chestcompressions200 chestcompressions200 chestcompressionsAnalysisAnalysisAnalysisBVM or PassiveInsufflation 15L NRBBegin IVAdminister 1 mgIV EpinephrineResume Standard ACLSConsider EndotrachealIntubationHere you see the Cardiocerebral Resuscitation protocol which was presented earlier by Dr. Bobrow.For the sake of this presentation we will focus on the box shaded yellow in the lower left hand corner. Paramedics have the option to initially manage the airway with active bag-valve-mask ventilation at a rate of 8-10 ventilations/minute or with passive oxygen insufflation using a NRB facemask with oxygen flowing at 15L/min.So, how did we get here?If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis
28Results Survival to Hospital Discharge from OHCA POI50%40%30%20%10%0%21/46BVMP=.001P=.14445.7%% Survival to Hospital Discharge14/77Here are the survival rates to hospital dischargeWhen looking at all arrests which met the inclusion criteria the survival was 11.7% in those managed with passive oxygen insufflation and 8% in those managed with active bag-valve-mask ventilation. There was not a statistical difference between the two groups.In the case of witnessed VF arrests the survival rate in those managed with passive oxygen insufflation was 45.7% and the survival rate in those managed with active bag-valve-mask ventilation was 18.2%. P<.00124/20630/37611.7%18.2%8.0%All Cardiac ArrestsWitnessed with VF
29Comparison of Major Outcomes Odds Ratios Outcomes POI vs. BVMPrimarySurvival to hospital discharge, % 8.0 vs. 11.7Odds ratio (95% CI) 1.7 ( )Survival with witnessed VF, % 18.2 vs. 45.7Odds ratio (95% CI) 5.7 ( )Using our logistic regression model, the odds of survival were 5.7 times higher in the witnessed VF arrests receiving passive oxygen insufflation compared to active bag-valve-mask ventilation.The model is adjusted for age, gender, location, bystander CPR, ventricular fibrillation, witnessed, and EMS dispatch to arrival interval
30ConclusionWidespread implementation of Cardiocerebral Resuscitation resulted in a significant improvement in adult OHCA survival compared with routine Advanced Life Support care over the same time period in ArizonaIn conclusion,Widespread implementation of Cardiocerebral Resuscitation resulted in a significant improvement in adult OHCA survival compared with Routine Advanced Life Support Care over the same time period in Arizona.
31American Heart Association Best Resuscitation Abstract "Statewide Survival From Out-of-Hospital Cardiac Arrest Improves with Widespread Implementation of Cardiocerebral Resuscitation"American Heart AssociationBest Resuscitation AbstractScientific Sessions 2007
34Important Questions:Perhaps witnessed VF but what about unwitnessed VF, asystole and PEA?What part of the CCR protocol is most critical?What is the optimal training method and retraining frequency?Will CCC-CPR truly improve bystander CPR rates?
36Initiative for Excellence in CPR Sarver Heart CenterSHARE ProgramInitiative for Excellence in CPRCardiocerebral ResuscitationBe A Lifesaver (Lay individuals)New ACLS Algorithm (Dispatchers, Firefighter/Paramedics and Medical Personnel)Post Resuscitation Care (In-Hospital)
37HOW DO WE FURTHER IMPROVE SURVIVAL? Therapeutic Hypothermia
39Therapeutic hypothermia had been advocated for decades as a treatment to improve neurologic outcome after cardiac arrest. The early studies focused on moderate hypothermia, which was associated with complications and was not clearly beneficial. Over the past decade, studies focused on mild hypothermia with target temperatures of 32ºC – 34ºC. Two recent multi-centered, randomized, controlled trials have demonstrated improved neurologic outcome with mild therapeutic hypothermia applied to comatose survivors after cardiac arrest compared to a normothermic control group.
41Reperfusion InjuryReperfusion injury is defined as “damage observed after restoration of blood flow to ischemic tissues”There are three potential treatment modalities to counteract the untoward effects of reperfusion:Increased ICU care and length of stayAntioxidantsHypothermia inductionThe use of antioxidants has been studied extensively in animals and has not been favorable. The antioxidants must be administered exactly when blood flow reperfusion begins for it to be effective (useful in cath lab)4141
42Clinical Hypothermia Mechanism of Action There are three distinct stages of cerebral injury after hypoxic insultEarlyIntermediateLateTherapeutic hypothermia is considered to be neuroprotective by acting at each of the three stages of injury42
43Mechanism of Hypothermia Decrease in cerebral metabolism6% reduction for every 10C drop in temperatureSuppression of reperfusion injuryDecreased free radical productionReduction in excitatory neurotransmittersSuppression of Ca+2 mediated cell deathAnti-inflammatory effectsNolan et al. (2003) CirculationFroehler and Geocadin. (2007) J of Neuro Sci
45Mild Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest (HACA) Patients with witnessed cardiac arrest from VF or pulseless VT, years of age, estimated 5-15 minutes to attempted resuscitation, and less than 60 minutes from collapse to restoration of spontaneous circulation275 patients of 3,551 cardiac arrests studied137 patients received hypothermiaDr. Fritz Sterz, Vienna, Austria, and The Hypothermia After Cardiac ArrestStudy Group, N Engl J Med 2002; 346:
46Hypothermia in Cardiac Arrest European experience Normothermia pts had target temperature of 37o CPts assigned to hypothermia had target temp of 32-34o C by use of an air cooled tent and mattresshypothermia was maintained for 24 hrs followed by passive rewarming over 8 hrs
47Bladder Temperature Course Normothermia ( n = 124)Hypothermia ( n = 123)Dr. Fritz Sterz, Vienna, Austria and The Hypothermia After Cardiac ArrestStudy Group, N Engl J Med 2002; 346:
48Hypothermia in Cardiac Arrest European experience Outcomes (at 6 mo):55% of the HT group had a “favorable outcome” compared to 39% in the NT group, p = 0.009mortality was 41% in the HT group compared to 55% in the NT group,p= 0.02The HACA Study Group, NEJM:2002:346:549-56
50Hypothermia in Cardiac Arrest the Melbourne experience NT pts had target temperature of 37o CHT pts had target temp of 33oC by extensive application of ice packs43 pts were randomized to HT, 34 to NTHypothermia was maintained for 12 hours then were actively rewarmed at 18 hours for the next 6 hours
51Hypothermia in Cardiac Arrest the Melbourne experience Outcomes:49% of the HT group had a “good outcome” compared with 26% in the NT group, (p<0.05)mortality was 51% in the HT group and 68% in the NT group, (p=NS)
54Compare ICU Strategies (Gropper, Anesth Analg 2004: 99:566) Treatment NNT (mortality)Early Goal-directed therapy 7Low-dose steroid 10ARDSnet low TV ventilation 12Activated protein CIntensive glycemic control 28Hypothermia
55Conclusions“In patients who have been successfully resuscitated after cardiac arrest due to ventricular fibrillation, therapeutic mild hypothermia increased the rate of a favorable neurologic outcome and reduced mortality.”-from The Hypothermia After Cardiac Arrest Study Group“…treatment with moderate hypothermia appears to improve outcomes in patients with coma after resuscitation from out-of-hospital cardiac arrest.”-from SA Bernard et al
57RecommendationsUnconscious adult patients with return of spontaneous circulation (ROSC) after out-of hospital cardiac arrest should be cooled to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours when the initial rhythm was ventricular fibrillation. Class IIaSimilar therapy may be beneficial for patients with non-VF arrest out of hospital or for in-hospital arrest. Class IIbAmerican Heart Association 2005 Guidelines57
58……Endorsed by the International Liaison Committee on Resuscitation Nolan JP, et al. An advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation. Resuscitation. 2003; 57:
59Post Resuscitation Care in Arizona A 2006 survey of 61 acute care hospitals in Arizona revealed that only 5 hospitals had done TH and only 2 hospitals had TH protocols.None of the patients in the SHARE database received TH.Snyder Q, et al. Western Journal of Emergency Medicine Vol. 9, No. 1, Article 26
60Optimal treatment during reperfusion Active and optimalintensive caretreatment!PCI/thrombolysis (if indicated)Initiate coolingOptimalisation of hemodynamicsFast inductionStable maintenanceSlow rewarming
62Practical Approach to TH Induction PhaseCold IV saline is bestNG Lavage may helpCold packs placed in groin and axillaMaintenance PhaseBlanket is cheap and effectiveIntravascular catheterExternal cooling padsRewarming PhaseInternal or external or warming blankets0.25 – 0.5 degrees C per hour
63Alsius IVTM™ Vein Placement options: Femoral Subclavian Internal jugularAlsius catheters also provide triple-lumen central venous access.
66Treatment of Comatose Survivors of Out-Of-Hospital Cardiac Arrest with Induced Hypothermia (Bernard) Cooling Device
67The Shivers ! Normal people will shiver and not cool more than 1 °C We can abate that with benzos or propofolLast resort is paralysis, but watch for seizuresCold IVF gets people cold faster, but you will need more than fluids to maintain.
69Post Resuscitation Care Oslo, Norway Experience Found that only 34% of patients initially resuscitated and delivered to the ED survived to dischargeThey Formalized an approach to post-resuscitation care:Therapeutic HypothermiaPCI when indicatedVentilation ControlGlucose ControlHemodynamic ControlSunde K, Steen PA and Associates
70Aggressive Post Resuscitation Care Saves Lives 60%50%40%30%20%10%59%p < 0.05Survival34%BeforeAfterPytte M, Jensen LP, Smedsrud C, Jacobsen D, Mangschau A, Sunde K.Oslo, Norway
73Brian Duffield,Finishing the 3 mileRough Water Swimin the Pacific Oceanon Sept 9, 2007.16 months after beingresuscitated fromout-of-hospitalcardiac arrest and then receiving therapeutic hypothermia and early cath/PCI.
75What could EMS offer the pt? 22 pts post ROSC who remained comatose30ml/kg of ice-cold saline given via peripheral IV or femoral central line over 30 min after patient evaluated and paralyzedDecreased core temp from 35.5 to 33.8°C
77Prehospital Cooling Hypothermia post-cardiac arrest Use of ice cold IV LR in pre-hospital for comatose pts post arrestPts given 30cc/Kg at rate of 100 ml/minAir ambulance with 25 min infusionPts reached target temp of 34 C with arrival to EDResuscitation. 2004:62:
81Formal Designation of Cardiac Arrest Centers Protocol and technique for TH24/7 PCI capability and protocol for evalProtocol for Termination of CareProtocol for organ procurementCollect 1 page data formParticipation in the CAC Consortium
84HIPAA Compliant Pursuant to 45 CFR § (b) of the HIPAA Privacy Rule, covered entities may disclose, without individual authorization, protected health information to public health authorities “…authorized by law to collect or receive such information…”The Bureau of EMS & Trauma System has authority to collect and receive protected health information and related records for public health purposes pursuant to A.R.S. Title 36, Chapter In January 2005, the SHARE program was designated a public health program by the Arizona Department of Health Services.
90Summary Hypothermia is part of a total care package A protocol for therapeutic hypothermia and PCI is necessary to assure efficient treatment and optimal results.TH should be initiated ASAP after ROSC, but appears successful even if delayed 4-6 hours.System-wide implementation of standardized post resuscitation care is feasible and will save lives.
91Cardiac Arrest Centers Arizona Already 15 Centers> 200 patients per year statewide will benefit from this system enhancement