1. 2015 THE STATE OF RESUCITATION

2.  Chain of Survival  Immediate Recognition  Early CPR  Rapid Defib  Effective ALS  Intergrated Post Care  CAB not ABC  No breathing or only gasping  Pulse checks limit to ten seconds THE CPR WE KNOW AND LOVE

3.  Push hard push fast  Lower half of the sternum  Allow for full chest recoil  *Rate at least 100 per minute*  Depth 1/3 for Ped to at least 2 inches for adults  Limit interruptions  Compression  One rescuer  Adult-30:2  Ped (Infant and Child)-30:2  Two Rescuer  Adult-30:2  Ped (Infant and Child) 15:2 COMPRESSION

4.  Low pressure  Patients with obstructed airways or poor lung compliance may require more  Chest rise  Rate  Adult 1 breath every 5-6 seconds  Pediatric 1 breath every 3-5 seconds  Asynchronous with Advanced Airway VENTILATIONS

5.  Collective learning  Increase learning rate  Business “SAVING LIVES” CHANGES & WHY THEY ARE IMPORTANT?

6.  Compressions  Pit crew  CCR  Ventilations  O2  ??????????? WHAT ARE THE CHANGES?

7. Rate and depth Metronome Mechanical devices COMPRESSIONS

8.  Chest Compression fraction  Time of the chest  Goal 80%  Rates 100-120 per minute.  Depth still 2 inches and 1/3 in children  Full chest recoil avoid excessive ventilations RATE AND DEPTH

9.  Metronome-Life Pack 15  Physio-control TFI and Zoll METRONOME AND COMPRESSION MEASUREMENT

10.  Piston  Active Compression-Decompression ACD devices  Load distributing bands  Perceived benefits  Final Conclusion-MFD and RAA MECHANICAL DEVICES

11.  Pit Crew CPR  Each responder has one function  Engineered to be the same  Priorities are the same each time  Compression-CF  Defibrillation-Shock/Don’t shock, pre-charge  Controlled ventilations  Stay and Play not Load and Go PIT CREW CPR

12.  Goal=Less than 10 second break in every 2 minute cycle of CPR  30:2  100 compressions/min =18s for compressions  5 second break for ventilations every 30 compressions?  18 of every 23s in active compression is 78%  NOT counting other breaks in CPR  Pit Crew  Continuous compressions w/asynchronous ventilation  10s break every 2 min is 92%  5s break every 2 min is 96% PIT CREW

13. PIT CREW CPR

15.  Components  1. Continuous chest compression without ventilations  2. Deemphasizing –intubations, ventilations but emphasize CCC early defibrillation and early administrations of EPI CARDIOCEREBRAL RESUSCITATION

16. Hyperventilation Resqpod Capnnometry readings VENTILATIONS

17.  Hyperoxia  AMI-Increase systemic Vascular resistance, decrease cardiac output and stroke volume  Cardiac arrest-poor neurological outcomes  COPD-Austin COPD study  2% vs 9%  Goal  Ischemia and infarction aim for mid 90 but not 98-100  94-95% stable  89-92% COPD  Avoid high flow 02 in patients with stable saturations OXYGEN

18.  Diffusion of 02  Decreasing intra-thoracic pressure  NC during intubation or NRB during CPR PASSIVE OXYGENATION

19.  Resuscitations Outcomes Consortium (ROC)  ETI VS SGA 8,847 patients underwent ET compared to 1,968  Neurological intact ET=4.7 and SGA=3.9  Japanese 2013 study  ETI and SGA new skills  BVM=2.6 times better survival  Comparable to the CARES study  SGA first line airway in Cardiac arrest  Understanding the effects of Positive Pressure Ventilations  Bottom Line-What do you do?  Pre-hospital Airway management and Neurological outcomes are linked the question is why? ETI VS. SGA

20.  Detrimental impact  Common in hospital and pre-hospital  Effects  Tools HYPERVENTIALTION

21.  What is it?  “The ResQPOD is an impedance threshold device (ITD) that provides Perfusion on Demand (POD) by regulating pressures in the thorax during states of hypotension.  Early studies  Pirallo compared to “sham” device  Improved BP in arrest victims  ROC Primed-no improvement in outcomes  Increased Resuscitation results when used with other Tech. RESQ-POD

22.  What are the reading associated with ROSC?  Spontaneous increase to values between 35-45  <less than 10 ROSC unlikely  AHA recommendations:  Confirm placement of ET tube and monitor waveform.  Monitor the adequacy of ventilation and oxygenation.  Monitor CPR quality, optimize chest compression, detect ROSC  if waveform capnography is less than 10mm hg improve CPR. CAPNOGRAPHY READINGS

23. Sequential defibrillation Cardiac rhythm review DEFIBRILLATION

24.  Double defib?  Last ditch effort  Continuous V-tach/V-fib  The science  The how SEQUENTIAL DEFIBRILLATION

25.  Resuscitation 2014  Electrical exposure risk associated with hands-on defibrillation  Study outcomes  Safety of HOD not known  If you do make sure you are wearing gloves  Do not place hands on pads  HOD or not minimize pre-shock pause  Large real life study needed HANDS ON DEFIBRILATION

26. Old standbys DRUGS

27.  Central ROLE???  Japanese study 2007-2010  2,000 v-tach and v-fib/10,000 PEA and Asystole  Did receive ROSC 17 vs 13.4 % and 4 and 2.4%  Poor neurological outcomes  Australians study 2011  ROSC but no changes in hospital discharge  Other Drugs with EPI  Vasopressin and steroids  Greek Study in VSE (vasopressin, steroids, epi)  ROSC and hospital charge 13.9% vs 5.1% EPI

28.  University of Warwick  Poss. published 2019?  Public out cry UK STUDY

29. Theureptic hypothermia Reprofusion centers AFTER CARE

30.  2010  AHA “ The 2010 AHA Guidelines for CPR and ECC recommends cooling comatose (i.e. lack of meaningful response to verbal commands) adult patients with ROSC after out- of-hospital VD cardiac arrest to 32 to 34 degrees for 12-24 hours. Healthcare providers should also consider induced hypothermia for comatose adult patients with ROSC after in-hospital cardiac arrest of any initial rhythm or after out-of-hospital cardiac arrest with an initial rhythm of PEA or Asystole” 2010 ACLS provider manual”  Science= Decrease or suppress many of the chemical reactions that lead to cell death/Decrease Cerebral Met. Rate  2014  JAMA-Effect of Pre-hospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults with Cardiac Arrest Randomized Clinical trial  Outcomes  No improvement in any Neuro status group  EMS group increase in re-arrest and pulmonary edema  What is Not said-Should we cool or not cool to 33 C/Difference in Urban Vs. Rural.-Currently TH exact role unknown THERAPEUTIC HYPOTHERMIA

31.  Evidence for taking patients to centers where they can perform angiography (PCI) and hypothermia.  “organized post-arrest care with an emphasis on multi- disciplinary programs that focus on optimizing hemodynamic, neurologic, and metabolic function may improve survival to hospital discharge among victims who achieve ROSC following cardiac arrest either in-or out of hospital” Jems 2012 EMS State of the Science  Bypassing closer hospitals? Page 28 ACLS provider manual  ECMO example from Jems REPERFUSION CENTERS

32.  AHA ACLS  ROSC?  Presence of reliable data indicating death  DNR  Consider other issue drug overdose and hypothermia  Not every patient should be transported (P.91 Acls)  Capnography >10mg  Resuscitating beyond the 25 minute mark  Standard in ACLS  WHAT IS THE NEUROLOGICAL OUTCOME OF THESE PATEINTS?  CPC values of 1 or 2  Better question is what is the point for ROSC and good neurlogical outcomes FIELD TERMINATION

33.  TAKE 10 is a community-focused effort to improve bystander CPR rates and thus improve survival. Learning chest compression only CPR for adults is simple. TAKE 10 is a 10 minute training session that teaches compression only CPR. GETTING THE CPR MESSAGE OUT https://www.youtube.com/watch?v=Rkryc2 5Qsm8

34.  Change is coming everyday whether we like it or not  CPR needs to be performed flawlessly  Focus on minimizing all delays i.e. charging, time off chest  EPI role in arrest remains unknown  O2 is not benign drug.  Therapeutic hypothermia doesn’t appear to have any proven benefits it may be started at the hospital. TAKE AWAY MESSAGES

35. THE END

36.  Example Greater Miami Valley EMS protocols for the treatment of ROSC.  See handouts  Ice packs/chilled fluid HYPOTHERMIA PROTOCOL