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The Arizona Cardiac Arrest Center Consortium Ben Bobrow, MD Assistant Professor, Department of Emergency Medicine, Mayo Clinic Hospital, Medical Director,

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Presentation on theme: "The Arizona Cardiac Arrest Center Consortium Ben Bobrow, MD Assistant Professor, Department of Emergency Medicine, Mayo Clinic Hospital, Medical Director,"— Presentation transcript:

1 The Arizona Cardiac Arrest Center Consortium Ben Bobrow, MD Assistant Professor, Department of Emergency Medicine, Mayo Clinic Hospital, Medical Director, Bureau of EMS & Trauma System Ben Bobrow, MD Assistant Professor, Department of Emergency Medicine, Mayo Clinic Hospital, Medical Director, Bureau of EMS & Trauma System

2 PRESENTER DISCLOSURE INFORMATION Ben Bobrow, MD Disclosure Information The following relationships exist related to this presentation: None

3 Arizona 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

4 Discussion Goals Review current updates in resuscitation including importance of high quality, minimally interrupted CPR Confer the role of therapeutic hypothermia in post-cardiac arrest care Describe the Arizona Cardiac Arrest Center model of care

5 Approximately 5,000 SCA/YR in AZ

6 Out of Hospital Cardiac Arrest: A Common Disease ~1000 Americans will suffer OHCA today ~1000 Americans will suffer OHCA tomorrow 25+ will suffer OHCA during this talk High morbidity and mortality –47% never make it to the hospital

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8 Where Can EMS Make A Difference in Outcomes? Cancer Pneumonia AIDS Kidney Disease Diabetes Alzheimer’s NOT YET Cardiac Arrest Major Trauma ST-Elevation MI Acute Stroke PROVEN!

9 Different Approach to OHCA OHCA is a major public health problem We SHOULD maximize our resources and collaborations with the goal of improving survival We NEED to have a REALISTIC idea of what happens in the field where the battle is fought Emergency medicine leaders MUST guide the community on how to bridge the gap between current knowledge and practice

10 Model for OHCA Collaboration AHA Municipal FDs Public Health Private Ambulance Local Hospitals Professional Societies Private Industry University Research Public Safety Officers Public

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12 Apache Junction FDKingman FDRiver Medical Ambulance Arivaca FDLake Mohave Ranchos FDRural Metro Avondale FDLifeline AmbulanceScottsdale FD Blue Ridge FDLifestar AmbulanceSedona FD Buckeye Valley FDMaricopa FDSeligman FD Chandler FDMayer FDSonoita - Elgin FD Central Yavapai FDMesa FDSouthwest Ambulance Chino Valley FDMontezuma/Rim Rock FDSummit FD Daisy Mountain FDNogales FDSun City FD Elephant Head Volunteer FDNogales Suburban FDSun City West FD El Mirage FDNorthwest FDSun Lakes FD Flagstaff FDPage FDSurprise FD Gila River Indian Community EMS Patagonia Lake State Park/Sonoita Creek State Natural Area FDTempe FD Gilbert FDPatagonia Volunteer FDTolleson FD Glendale FDPayson FDTonopah Valley FD Golden Valley FDPeach Springs EMSTubac FD Goodyear FDPeoria FDTucson FD Grapevine Mesa FDPhoenix FD United States Border Patrol - AZ Green Valley FDPine Lake FDTusayan FD Guadalupe FDPinewood FDVerde Valley FD Guardian Medical TransportPinion Pine FDWalker FD Helmet Peak FDPMTWestern Air Rescue Hualapai Valley FDPrescott FDYarnell Fire District Puerco Valley FDYuma FD 6/24/ SHARE Participants

13 OHCA Survival in Arizona Arizona 2004 With so few survivors, we felt compelled to make modifications to protocol based upon current evidence and track the results closely Bobrow B et al. Circulation. 2006; 114:II 350. % 3

14 Arizona ‘04 Neurologically normal survival (%) Chicago ‘87 Ontario ‘89 LA ‘00 Seattle ‘01 OHCA Survival Eckstein M et al. Annals of Emerg Med. 2005;45: Issue 5; Rea T et al. Circulation. 2003;107:

15 Many Reasons for Low OHCA Survival: Poor public knowledge of cardiac arrest Delayed time to first defibrillation Low rates of bystander CPR Inconsistent quality of professional CPR Inconsistent post cardiac arrest care WE haven’t adequately implemented what we already know

16 Standard CPR (with breaths) vs. CC alone Berg et al, 2001 Blood pressure Time = chest compression

17 Standard CPR (with breaths) vs. CC alone Berg et al, 2001 Blood pressure Time = chest compression

18 Hyperventilation during CPR Aufderheide et al. Circulation 2004; 109:1960-5

19 Three-Phase Model of VF Arrest Time (min) Circulatory Phase Electrical Phase Metabolic Phase 0 100% Myocardial ATP Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8

20 Cardiocerebral Resuscitation (CCR) 200 chest compressions 200 chest compressions Single shock without pulse check or rhythm analysis BVM or Passive Insufflation 100% FIO2 Begin IV Analysis 200 chest compressions Single shock if indicated without pulse check or rhythm analysis Analysis Single shock if indicated without pulse check or rhythm analysis Resume Standard ACLS Consider Endotracheal Intubation 200 chest compressions CC Only EMS arrival Administer 1 mg IV Epinephrine Analysis If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis

21 CCR vs AHA Guidelines CCC-CPR for bystanders ACLS: Passive O2/BVM –(protocol delayed ETT) 200 CC prior to shock 200 CC immediately post shock Early epinephrine IO/IV Hypothermia for all comatose 30:2 CC to V (Bystander “ Hands-Only CPR ” ) ACLS: 8-10 breaths/min –(timing of ETT by provider) Optional 5 cycles of 30:2 prior 5 cycles of 30:2 post shock Epinephrine second cycle Hypothermia for VF/VT comatose

22 Hypothesis OHCA victims in Arizona receiving Cardiocerebral Resuscitation would have higher survival rates than victims receiving routine Advanced Life Support

23 Utstein style database October 2004 to August of 61 (18%) elected to change to CCR Train-the-trainer program January 2005 to April 2007 ~3,000 EMT (B) and (P) trained Methods: Data Collection and Training

24 598 CCR Total cardiac arrests n= 3, excluded (age <18 yrs) 3,158 adult 874 excluded –673 non-cardiac –139 EMS witnessed –62 missing outcome 2,284 arrests of cardiac etiology 1,686 Routine ALS Enrollment

25 Results Characteristics of OHCA Victims SD = Standard deviation*p<0.05**p<0.01 CharacteristicCCR (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)* 76.1 (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) 32.6 (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)

26 Results Survival from Out of Hospital Cardiac Arrest Survival to Hospital Discharge (%) All cardiac arrests Witnessed with VF (55/598) (61/1686) (36/128) (38/348) CCR ALS

27 Cardiocerebral Resuscitation 200 chest compressions 200 chest compressions Single shock without pulse Check or rhythm analysis BVM or Passive Insufflation 15L NRB Begin IV Analysis 200 chest compressions Single shock if Indicated without pulse check or rhythm analysis Analysis Single shock if Indicated without pulse check or rhythm analysis Resume Standard ACLS Consider Endotracheal Intubation 200 chest compressions CCC Only EMS arrival Administer 1 mg IV Epinephrine Analysis If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis

28 Results Survival to Hospital Discharge from OHCA % Survival to Hospital Discharge 50% 40% 30% 20% 10% 0% All Cardiac Arrests Witnessed with VF 11.7% POI BVM 24/ % 30/ % 21/ % 14/77 P=.144 P=.001

29 Comparison of Major Outcomes Odds Ratios The model is adjusted for age, gender, location, bystander CPR, ventricular fibrillation, witnessed, and EMS dispatch to arrival interval Outcomes POI vs. BVM Primary Survival to hospital discharge, %8.0 vs Odds ratio (95% CI)1.7 ( ) Survival with witnessed VF, %18.2 vs Odds ratio (95% CI)5.7 ( ) Outcomes POI vs. BVM Primary Survival to hospital discharge, %8.0 vs Odds ratio (95% CI)1.7 ( ) Survival with witnessed VF, %18.2 vs Odds ratio (95% CI)5.7 ( )

30 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

31 "Statewide Survival From Out-of-Hospital Cardiac Arrest Improves with Widespread Implementation of Cardiocerebral Resuscitation" American Heart Association Best Resuscitation Abstract Scientific Sessions 2007

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34 Important 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?

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36 Cardiocerebral Resuscitation 1.Be A Lifesaver (Lay individuals) 2.New ACLS Algorithm (Dispatchers, Firefighter/Paramedics and Medical Personnel) 3.Post Resuscitation Care (In-Hospital) Sarver Heart Center SHARE Program Initiative for Excellence in CPR

37 HOW DO WE FURTHER IMPROVE SURVIVAL? Therapeutic Hypothermia

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40 For 50 years we have been sitting here….

41 41 Reperfusion Injury Reperfusion 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 stay –Antioxidants –Hypothermia induction

42 42 Clinical Hypothermia Mechanism of Action There are three distinct stages of cerebral injury after hypoxic insult –Early –Intermediate –Late Therapeutic hypothermia is considered to be neuroprotective by acting at each of the three stages of injury

43 Mechanism of Hypothermia Decrease in cerebral metabolism –6% reduction for every 1 0 C drop in temperature Suppression of reperfusion injury –Decreased free radical production –Reduction in excitatory neurotransmitters –Suppression of Ca +2 mediated cell death –Anti-inflammatory effects Nolan et al. (2003) Circulation Froehler and Geocadin. (2007) J of Neuro Sci

44 Proof of Theory Studies

45 Mild 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 circulation 275 patients of 3,551 cardiac arrests studied 137 patients received hypothermia Dr. Fritz Sterz, Vienna, Austria, and The Hypothermia After Cardiac Arrest Study Group, N Engl J Med 2002; 346:

46 Hypothermia in Cardiac Arrest European experience Normothermia pts had target temperature of 37 o C Pts assigned to hypothermia had target temp of o C by use of an air cooled tent and mattress hypothermia was maintained for 24 hrs followed by passive rewarming over 8 hrs

47 Bladder Temperature Course Normothermia ( n = 124) Hypothermia ( n = 123) Dr. Fritz Sterz, Vienna, Austria and The Hypothermia After Cardiac Arrest Study Group, N Engl J Med 2002; 346:

48 Hypothermia 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 = mortality was 41% in the HT group compared to 55% in the NT group, p= 0.02 The HACA Study Group, NEJM:2002:346:549-56

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50 Hypothermia in Cardiac Arrest the Melbourne experience NT pts had target temperature of 37 o C HT pts had target temp of 33 o C by extensive application of ice packs 43 pts were randomized to HT, 34 to NT Hypothermia was maintained for 12 hours then were actively rewarmed at 18 hours for the next 6 hours

51 Hypothermia 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)

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53 HACA – Complications (all N.S. between groups) NT Hypothermia Bleeding19%26% Pneumonia29%37% Sepsis7%13% Pulmonary Edema 4%7% Renal Failure / HD10% / 4%10% / 4% Seizure 8%7% Serious Arrhythmia32%36% Pancreatitis1%1%

54 Compare ICU Strategies (Gropper, Anesth Analg 2004: 99:566) TreatmentNNT (mortality) Early Goal-directed therapy 7 Low-dose steroid10 ARDSnet low TV ventilation12 Activated protein C 17 Intensive glycemic control28 Hypothermia

55 Conclusions “ 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

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57 57 Recommendations Unconscious 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 IIa Similar therapy may be beneficial for patients with non-VF arrest out of hospital or for in-hospital arrest. Class IIb American Heart Association 2005 Guidelines

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:

59 Post 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 2008 Vol. 9, No. 1, Article 26

60 Active and optimal intensive care treatment! PCI/thrombolysis (if indicated) Initiate cooling Optimalisation of hemodynamics Optimal treatment during reperfusion Fast induction Stable maintenance Slow rewarming

61 38°C 37°C 36°C 35°C 34°C 33°C 32°C 31°C 30°C Brain Injury Brain Protection Dysrhythmia / Irritability Positive Inotropy, Increased SV, Decreased HR, Heart Protection 32ºC - 34ºC

62 Practical Approach to TH Induction Phase –Cold IV saline is best –NG Lavage may help –Cold packs placed in groin and axilla Maintenance Phase –Blanket is cheap and effective –Intravascular catheter –External cooling pads –Rewarming Phase –Internal or external or warming blankets –0.25 – 0.5 degrees C per hour

63 Alsius IVTM™ Vein Placement options: Femoral Subclavian Internal jugular Alsius catheters also provide triple-lumen central venous access.

64 Medivance “Arctic Sun”

65 The LRS ThermoSuit ® System

66 Treatment of Comatose Survivors of Out-Of-Hospital Cardiac Arrest with Induced Hypothermia (Bernard) Cooling Device

67 The Shivers ! Normal people will shiver and not cool more than 1 °C We can abate that with benzos or propofol Last resort is paralysis, but watch for seizures Cold IVF gets people cold faster, but you will need more than fluids to maintain.

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69 Post Resuscitation Care Oslo, Norway Experience Found that only 34% of patients initially resuscitated and delivered to the ED survived to discharge They Formalized an approach to post- resuscitation care: –Therapeutic Hypothermia –PCI when indicated –Ventilation Control –Glucose Control –Hemodynamic Control Sunde K, Steen PA and Associates

70 Aggressive Post Resuscitation Care Saves Lives Survival 60% 50% 40% 30% 20% 10% BeforeAfter 34% 59% Pytte M, Jensen LP, Smedsrud C, Jacobsen D, Mangschau A, Sunde K. Oslo, Norway p < 0.05

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73 Brian Duffield, Finishing the 3 mile Rough Water Swim in the Pacific Ocean on Sept 9, months after being resuscitated from out-of-hospital cardiac arrest and then receiving therapeutic hypothermia and early cath/PCI.

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75 What could EMS offer the pt? 22 pts post ROSC who remained comatose 30ml/kg of ice-cold saline given via peripheral IV or femoral central line over 30 min after patient evaluated and paralyzed Decreased core temp from 35.5 to 33.8°C

76 Bernard SA, et al. Resuscitation 2003; 56:9-13

77 Prehospital Cooling Hypothermia post-cardiac arrest Use of ice cold IV LR in pre-hospital for comatose pts post arrest Pts given 30cc/Kg at rate of 100 ml/min Air ambulance with 25 min infusion Pts reached target temp of 34 C with arrival to ED Resuscitation. 2004:62:

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81 Formal Designation of Cardiac Arrest Centers Protocol and technique for TH 24/7 PCI capability and protocol for eval Protocol for Termination of Care Protocol for organ procurement Collect 1 page data form Participation in the CAC Consortium

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84 HIPAA 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 21.1 In January 2005, the SHARE program was designated a public health program by the Arizona Department of Health Services.

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86 Implementation Strategy Handout to each interested Cardiac Arrest Center Consortium member

87 Sample protocols du/resuscitation/Hypothe rmia.htm

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90 Summary 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.

91 Cardiac Arrest Centers Arizona > 200 patients per year statewide will benefit from this system enhancement Already 15 Centers

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93 Thank you Our goal is for Arizonans to have the highest survival rate in the world for cardiac arrest victims.


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