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

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 6

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
As 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.

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

12. 71 SHARE Participants Apache Junction FD Kingman FD
River Medical Ambulance
Arivaca FD
Lake Mohave Ranchos FD
Rural Metro
Avondale FD
Lifeline Ambulance
Scottsdale FD
Blue Ridge FD
Lifestar Ambulance
Sedona FD
Buckeye Valley FD
Maricopa FD
Seligman FD
Chandler FD
Mayer FD
Sonoita - Elgin FD
Central Yavapai FD
Mesa FD
Southwest Ambulance
Chino Valley FD
Montezuma/Rim Rock FD
Summit FD
Daisy Mountain FD
Nogales FD
Sun City FD
Elephant Head Volunteer FD
Nogales Suburban FD
Sun City West FD
El Mirage FD
Northwest FD
Sun Lakes FD
Flagstaff FD
Page FD
Surprise FD
Gila River Indian Community EMS
Patagonia Lake State Park/Sonoita Creek State Natural Area FD
Tempe FD
Gilbert FD
Patagonia Volunteer FD
Tolleson FD
Glendale FD
Payson FD
Tonopah Valley FD
Golden Valley FD
Peach Springs EMS
Tubac FD
Goodyear FD
Peoria FD
Tucson FD
Grapevine Mesa FD
Phoenix FD
United States Border Patrol - AZ
Green Valley FD
Pine Lake FD
Tusayan FD
Guadalupe FD
Pinewood FD
Verde Valley FD
Guardian Medical Transport
Pinion Pine FD
Walker FD
Helmet Peak FD
PMT
Western Air Rescue
Hualapai Valley FD
Prescott FD
Yarnell Fire District
Puerco Valley FD
Yuma FD
6/24/2008

13. OHCA Survival in Arizona50 40 30 20 10
With 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. 3
Arizona
2004
Bobrow B et al. Circulation ; 114:II 350.

14. Neurologically normal survival (%)
OHCA Survival 50 40 30 20 10
Neurologically normal survival (%) 16
Survival 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. 3 1 2 1
Chicago ‘87
Ontario ‘89
LA ‘00
Seattle ‘01
Arizona ‘04
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
Blood pressure
Time
= chest compression
Berg et al, 2001

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

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

19. Three-Phase Model of VF
100%
Myocardial ATP
Electrical
Phase
Circulatory
Phase
Metabolic
Phase 2 4 6 8 10 12 14 16 18 20
Arrest Time (min)
Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8

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

21. CCR vs. 2005 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: 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
We 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.

23. Methods: Data Collection and Training
Utstein style database
October 2004 to August 2007
11 of 61 (18%) elected to change to CCR
Train-the-trainer program
January 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.

24. 2,284 arrests of cardiac etiology
Enrollment
Total cardiac arrests
n= 3,329
171 excluded
(age <18 yrs)
3,158 adult
874 excluded
673 non-cardiac
139 EMS witnessed
62 missing outcome
Enrollment 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 etiology
1,686 Routine ALS
598 CCR

25. Results 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

26. Results Survival from Out of Hospital Cardiac Arrest
(36/128)
CCR 30 25 20 15 10 5
ALS
28.1
Survival 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)
10.9
9.2
(61/1686)
3.6
All cardiac arrests
Witnessed with VF

27. Cardiocerebral Resuscitation
Single shock if
Indicated without
pulse check or
rhythm analysis
Single shock if
Indicated without
pulse check or
rhythm analysis
Single shock
without pulse
Check or rhythm
analysis
EMS
arrival
CCC
Only•
200 chest
compressions
200 chest
compressions
200 chest
compressions
200 chest
compressions
Analysis
Analysis
Analysis
BVM or Passive
Insufflation 15L NRB
Begin IV
Administer 1 mg
IV Epinephrine
Resume Standard ACLS
Consider Endotracheal
Intubation
Here 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

28. Results Survival to Hospital Discharge from OHCA
POI
50%
40%
30%
20%
10% 0%
21/46
BVM
P=.001
P=.144
45.7%
% Survival to Hospital Discharge
14/77
Here are the survival rates to hospital discharge
When 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<.001
24/206
30/376
11.7%
18.2%
8.0%
All Cardiac Arrests
Witnessed with VF

29. Comparison of Major Outcomes Odds Ratios
Outcomes POI vs. BVM
Primary
Survival to hospital discharge, % 8.0 vs. 11.7
Odds ratio (95% CI) 1.7 ( )
Survival with witnessed VF, % 18.2 vs. 45.7
Odds 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

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

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?

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

37. HOW DO WE FURTHER IMPROVE SURVIVAL?
Therapeutic Hypothermia

39. Therapeutic 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.

40. For 50 years we have been sitting here….

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
The 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) 41 41

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 42

43. Mechanism of Hypothermia
Decrease in cerebral metabolism
6% reduction for every 10C 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 37o C
Pts assigned to hypothermia had target temp of 32-34o 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 = 0.009
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

50. Hypothermia in Cardiac Arrest the Melbourne experience
NT pts had target temperature of 37o C
HT pts had target temp of 33oC 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)

53. HACA – Complications (all N.S. between groups)
NT Hypothermia
Bleeding 19% 26%
Pneumonia 29% 37%
Sepsis 7% 13%
Pulmonary Edema 4% 7%
Renal Failure / HD 10% / 4% 10% / 4%
Seizure 8% 7%
Serious Arrhythmia 32% 36%
Pancreatitis 1% 1%

54. Compare ICU Strategies (Gropper, Anesth Analg 2004: 99:566)
Treatment NNT (mortality)
Early Goal-directed therapy 7
Low-dose steroid 10
ARDSnet low TV ventilation 12
Activated protein C
Intensive glycemic control 28
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

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 57

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 Vol. 9, No. 1, Article 26

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

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

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.

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
60%
50%
40%
30%
20%
10%
59%
p < 0.05
Survival
34%
Before
After
Pytte M, Jensen LP, Smedsrud C, Jacobsen D, Mangschau A, Sunde K.
Oslo, Norway

73. Brian Duffield,
Finishing the 3 mile
Rough Water Swim
in the Pacific Ocean
on Sept 9, 2007.
16 months after being
resuscitated from
out-of-hospital
cardiac arrest and then receiving therapeutic hypothermia and early cath/PCI.

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:

80. `

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

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

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

87. Sample protocols

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
Already 15 Centers
> 200 patients per year statewide will benefit from this system enhancement

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