SCD 2014: Update on Cardiac Resuscitation

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Christopher B. Granger, MD

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  • The four premier partners we invited into the HeartRescue Flagship Program include:
    The University of Washington/Seattle-King County (Drs. Graham Nichol, Mickey Eisenberg, Tom Rea, Michael Copass)
    University of Arizona/AZ Dept of Health (Drs. Ben Bobrow, Dan Spaite, Gordon Ewy)
    Duke University/Wake County EMS/NC State EMS (Drs. Jamie Jollis, Chris Granger, Brent Meyers, Greg Mears)
    University of Pennsylvania Center for Resuscitation Science (Drs. Lance Becker, Ben Abella)
    These four partners represent for us a well rounded picture of what today would be considered ‘best practices’ in resuscitation. Each partner has a set of strengths that can be shared with the others. We believe the creation of this program will inspire our partners to take their programs to the next level of excellence, through collaboration, communication, and commitment to implementing and replicating the systems-based approach to treating SCA.
  • Context The health and policy implications of regional variation in incidence and outcome
    of out-of-hospital cardiac arrest remain to be determined.
    Objective To evaluate whether cardiac arrest incidence and outcome differ across
    geographic regions.
    Design, Setting, and Patients Prospective observational study (the Resuscitation
    Outcomes Consortium) of all out-of-hospital cardiac arrests in 10 North American sites
    (8 US and 2 Canadian) from May 1, 2006, to April 30, 2007, followed up to hospital
    discharge, and including data available as of June 28, 2008. Cases (aged 0-108 years)
    were assessed by organized emergency medical services (EMS) personnel, did not have
    traumatic injury, and received attempts at external defibrillation or chest compressions
    or resuscitation was not attempted. Census data were used to determine rates
    adjusted for age and sex.
    Main Outcome Measures Incidence rate, mortality rate, case-fatality rate, and survival
    to discharge for patients assessed or treated by EMS personnel or with an initial
    rhythm of ventricular fibrillation.
    Results Among the 10 sites, the total catchment population was 21.4 million, and there
    were 20 520 cardiac arrests. A total of 11 898 (58.0%) had resuscitation attempted; 2729
    (22.9% of treated) had initial rhythm of ventricular fibrillation or ventricular tachycardia
    or rhythms that were shockable by an automated external defibrillator; and 954 (4.6%
    of total) were discharged alive. The median incidence of EMS-treated cardiac arrest across
    sites was 52.1 (interquartile range [IQR], 48.0-70.1) per 100 000 population; survival
    ranged from 3.0% to 16.3%, with a median of 8.4% (IQR, 5.4%-10.4%). Median ventricular
    fibrillation incidence was 12.6 (IQR, 10.6-5.2) per 100 000 population; survival
    ranged from 7.7% to 39.9%, with a median of 22.0% (IQR, 15.0%-24.4%), with significant
    differences across sites for incidence and survival (P.001).
    Conclusion In this study involving 10 geographic regions in North America, there
    were significant and important regional differences in out-of-hospital cardiac arrest
    incidence and outcome.
    JAMA. 2008;300(12):1423-1431
  • This map shows the emergency medical services route for the patient in case 1. Emergency medical services arrived at the patient's home (A) and transported him directly to a primary percutaneous coronary intervention center (C), bypassing a non–percutaneous coronary intervention hospital (B). Map created with the use of www.mapquest.com on November 22, 2010.
  • Chest Compression Fraction Determines Survival in Patients
    With Out-of-Hospital Ventricular Fibrillation
    Jim Christenson, MD; Douglas Andrusiek, MSc; Siobhan Everson-Stewart, MS; Peter Kudenchuk, MD;
    David Hostler, PhD; Judy Powell, BSN; Clifton W. Callaway, MD, PhD;
    Dan Bishop; Christian Vaillancourt, MD, MSc; Dan Davis, MD; Tom P. Aufderheide, MD;
    Ahamed Idris, MD; John A. Stouffer; Ian Stiell, MD, MSc; Robert Berg, MD;
    and the Resuscitation Outcomes Consortium Investigators
    Background—Quality cardiopulmonary resuscitation contributes to cardiac arrest survival. The proportion of time in
    which chest compressions are performed in each minute of cardiopulmonary resuscitation is an important modifiable
    aspect of quality cardiopulmonary resuscitation. We sought to estimate the effect of an increasing proportion of time
    spent performing chest compressions during cardiac arrest on survival to hospital discharge in patients with
    out-of-hospital ventricular fibrillation or pulseless ventricular tachycardia.
    Methods and Results—This is a prospective observational cohort study of adult patients from the Resuscitation Outcomes
    Consortium Cardiac Arrest Epistry with confirmed ventricular fibrillation or ventricular tachycardia, no defibrillation
    before emergency medical services arrival, electronically recorded cardiopulmonary resuscitation before the first shock,
    and a confirmed outcome. Patients were followed up to discharge from the hospital or death. Of the 506 cases, the mean
    age was 64 years, 80% were male, 71% were witnessed by a bystander, 51% received bystander cardiopulmonary
    resuscitation, 34% occurred in a public location, and 23% survived. After adjustment for age, gender, location, bystander
    cardiopulmonary resuscitation, bystander witness status, and response time, the odds ratios of surviving to hospital
    discharge in the 2 highest categories of chest compression fraction compared with the reference category were 3.01
    (95% confidence interval 1.37 to 6.58) and 2.33 (95% confidence interval 0.96 to 5.63). The estimated adjusted linear
    effect on odds ratio of survival for a 10% change in chest compression fraction was 1.11 (95% confidence interval 1.01
    to 1.21).
    Conclusions—An increased chest compression fraction is independently predictive of better survival in patients who
    experience a prehospital ventricular fibrillation/tachycardia cardiac arrest. (
  • SCD 2014: Update on Cardiac Resuscitation

    1. 1. Update on Cardiac Resuscitation inUpdate on Cardiac Resuscitation in North CarolinaNorth Carolina The problem, the solution, and howThe problem, the solution, and how you can helpyou can help Christopher Granger, MDChristopher Granger, MD
    2. 2. DisclosureDisclosure Research contracts: AstraZeneca, Novartis, GSK,Research contracts: AstraZeneca, Novartis, GSK, Sanofi-Aventis, BMS, The Medicines Company,Sanofi-Aventis, BMS, The Medicines Company, Astellas, and Boehringer IngelheimAstellas, and Boehringer Ingelheim Consulting/Honoraria: AstraZeneca, GSK, BMS, Lilly,Consulting/Honoraria: AstraZeneca, GSK, BMS, Lilly, Novartis, Roche, Boehringer Ingelheim, The MedicinesNovartis, Roche, Boehringer Ingelheim, The Medicines Company, Fibrex, and Sanofi-AventisCompany, Fibrex, and Sanofi-Aventis For full listing see wFor full listing see www.dcri.duke.edu/research/coi.jspww.dcri.duke.edu/research/coi.jsp
    3. 3. HeartRescue Partners Center for Resuscitation Science Van Diepen S. AHJ 2013 in press
    4. 4. https://racecars.dcri.duke.edu/
    5. 5. The problemThe problem  8000 people suffer cardiac arrest each year in8000 people suffer cardiac arrest each year in North CarolinaNorth Carolina  11% survival (cardiac etiology)11% survival (cardiac etiology)  25% get bystander CPR25% get bystander CPR  <2% get bystander AED use<2% get bystander AED use  Many do not get proven hospital treatments toMany do not get proven hospital treatments to improve survival: primary PCI if STEMI,improve survival: primary PCI if STEMI, temperature control, goal-directed ICU care, ICDstemperature control, goal-directed ICU care, ICDs
    6. 6. If you don’t measure it, you can’tIf you don’t measure it, you can’t improve itimprove it
    7. 7. Van Diepen S. AHJ 2013 Reporting Counties Limited Reporting – only select agencies Site set up in progress Future Sites April 2014: 83% of population covered
    8. 8. CARES RegistryCARES Registry
    9. 9. Good newsGood news Witnessed, shockable rhythm, and some interventionWitnessed, shockable rhythm, and some intervention by a bystander (CPR and/or AED):by a bystander (CPR and/or AED): 37% survived, mostly with good neurologic function37% survived, mostly with good neurologic function CARES Data, National, 2012CARES Data, National, 2012
    10. 10. Bad newsBad news In many regions, survival remains very lowIn many regions, survival remains very low
    11. 11. Variation in Survival for Cardiac ArrestVariation in Survival for Cardiac Arrest Resuscitations Outcomes ConsortiumResuscitations Outcomes Consortium Survival to Discharge for VF ArrestSurvival to Discharge for VF Arrest Nichol JAMA. 2008;300(12):1423-1431
    12. 12. ©2010, American Heart Association 132010 AHA Resuscitation
    13. 13.  57 year old man arrested at home in his kitchen57 year old man arrested at home in his kitchen  Got mmediate CPR by son, who called 9-1-1Got mmediate CPR by son, who called 9-1-1  EMS arrived 10 minutes later, defibrillated, prehospitalEMS arrived 10 minutes later, defibrillated, prehospital ECG showed inferior STEMIECG showed inferior STEMI  Cardioverted X 5 total from VF/VT, intubated, comaCardioverted X 5 total from VF/VT, intubated, coma  Actived Duke STEMI HotlineActived Duke STEMI Hotline  Taken across county line past Alamance RMC to Duke,Taken across county line past Alamance RMC to Duke, 32 minutes transport distance32 minutes transport distance
    14. 14.  Physical exam: unresponsive, HR 90s, BP 90/70,Physical exam: unresponsive, HR 90s, BP 90/70, pulmonary edema, heart sounds distant, no murmurpulmonary edema, heart sounds distant, no murmur  Taken to cath lab, where he had multiple additionalTaken to cath lab, where he had multiple additional arrests; IAPB for shockarrests; IAPB for shock  DTB 46 min; 1st ECG to balloon 91 minDTB 46 min; 1st ECG to balloon 91 min  Cooled with Arctic Sun X 24 hoursCooled with Arctic Sun X 24 hours
    15. 15. A Case of Cardiac Arrest and Cardiogenic Shock • IABP placed prior to PCI • 3 BMS (Vision stent) placed – 2.5 mm to 3.0 mm
    16. 16. Circulation 2011;124:851-856
    17. 17. Why did Mr. Snipe survive?Why did Mr. Snipe survive?  Son recognized arrestSon recognized arrest  Called 9-1-1Called 9-1-1  Initiated bystander CPRInitiated bystander CPR
    18. 18. Bystander CPRBystander CPR 2.4 times survival to hospital discharge2.4 times survival to hospital discharge 0.1 0.5 1 3 10 50 Baseline survival 0 – 2.1 2.1 – 4.1 4.2 – 6.7 6.8 – 9.0 9.1 + 5.0 4.0 2.7 1 1.2 Circ Cardiovasc Qual Outcomes. 2010;3:63-81 2.4 (95% CI 1.7 - 3.2)Overall
    19. 19. Compression only CPRCompression only CPR
    20. 20. Bystander CPR
    21. 21. Bystander CPR: Incidence and TypeBystander CPR: Incidence and Type 100% 80% 60% 40% 20% 0% 2005 2006 2007 2008 2009 SHARE - JAMA 2010 All LayAll Lay CPRCPR % Lay COCPR 28.2%28.2% 39.9% P = 0.001P = 0.001 16% 77% 41.5% relative increase
    22. 22. 35% 30% 25% 20% 15% 10% 5% 0% 17.7% 33.7% SurvivaltoHospitalDischarge Std-CPR CO-CPR P < 0.001 Witnessed/Shockable 7.8% Std-CPR 13.3% CO-CPR A. B.All OHCA AOR 1.6 (95% CI, 1.08-2.35) Bobrow, et al. JAMA 2010;304:1447-1454 Chest Compression-Only CPR by Lay Rescuers and Survival From Out-of-Hospital Cardiac Arrest
    23. 23. CPR TrainingCPR Training
    24. 24. NC House Bill 837 Passed in 2012 Requires AllNC House Bill 837 Passed in 2012 Requires All Public High School Students to be Trained in CPRPublic High School Students to be Trained in CPR Before Graduation by 2015Before Graduation by 2015
    25. 25. Movie Theater Public Service Announcement 135,000; 6.2 million impressions
    26. 26. 2700 trained at NC State Fair 2014
    27. 27. Meena and LeatriceTrain CPR atMeena and LeatriceTrain CPR at Science MuseumScience Museum
    28. 28. Can we identify patterns of frequencyCan we identify patterns of frequency of arrests, bystander CPR rates, time toof arrests, bystander CPR rates, time to response at neighborhood level toresponse at neighborhood level to improve care?improve care?
    29. 29. Attempted resuscitations 2009- 2010Attempted resuscitations 2009- 2010 Bystander CPR rates by NeighborhoodBystander CPR rates by Neighborhood Fosbol E. ACC 2013
    30. 30. Can we improve bystander CPR ratesCan we improve bystander CPR rates from 18% to 40% in Durham?from 18% to 40% in Durham?
    31. 31. Durham as case study in cardiac arrestDurham as case study in cardiac arrest  Bystander CPR rate in 2010 was 18% (24% nationally,Bystander CPR rate in 2010 was 18% (24% nationally, 40% in Seattle and Arizona)40% in Seattle and Arizona)  Duke is number one employer in DurhamDuke is number one employer in Durham  ““Hands-only CPR” can be taught with 5 minute trainingHands-only CPR” can be taught with 5 minute training modulemodule  Program to train all Duke employees to perform CPRProgram to train all Duke employees to perform CPR
    32. 32. NC Health SystemsNC Health Systems Number ofNumber of EmployeesEmployees Carolinas HealthCCarolinas HealthC 48,12048,120 UNCUNC 44,20044,200 Duke UDuke U 33,70533,705 24,40024,400 12,60012,600 WakeWake 8,4008,400
    33. 33. Walk the walk:Walk the walk: Health care organizations should takeHealth care organizations should take the lead and train ALL employeesthe lead and train ALL employees hands-only CPRhands-only CPR
    34. 34. Dispatcher InstructionDispatcher Instruction
    35. 35. Why did Mr. Snipe survive?Why did Mr. Snipe survive?  High quality CPRHigh quality CPR  EMS obtained 12-lead ECGEMS obtained 12-lead ECG  EMS activated the Duke cath labEMS activated the Duke cath lab  EMS bypassed a closer non-PCI centerEMS bypassed a closer non-PCI center
    36. 36. Chest compression fraction and survivalChest compression fraction and survival  506 patients with VF / VT and506 patients with VF / VT and no defib. before EMS arrival.no defib. before EMS arrival.  Electronically recordedElectronically recorded cardiopulmonary resuscitationcardiopulmonary resuscitation before the first shock.before the first shock.  51% bystander CPR51% bystander CPR  6 minutes call to scene6 minutes call to scene  11 minutes call to first shock.11 minutes call to first shock.  ROSC 72%ROSC 72%  Survived to discharge 23%Survived to discharge 23%  Survival closely linked toSurvival closely linked to compression fractioncompression fraction ROC Investigators Circulation. 2009;120:1241-1247. Percentagesurviving 0%-20%0%-20% Survival to discharge 81-100%81-100%41-60%41-60%21-40%21-40% 61-80%61-80% 20%20% 10%10% 0%0% 40%40% 30%30% Chest compression fraction
    37. 37. 39 | MDT Confidential Example of resuscitation WITHOUT feedback- NO ROSC Depth = 1.39 in. Rate = 148 CC/min CPR fraction = 51%
    38. 38. Pit Crew High Quality CPR: NCOEMS Protocol 21
    39. 39. Pit Crew Resuscitation
    40. 40. Why did Mr. Snipe survive?Why did Mr. Snipe survive?  Rapid primary PCIRapid primary PCI  Therapeutic hyperthermiaTherapeutic hyperthermia  Appropriate prognosticationAppropriate prognostication
    41. 41. Wait at least 5 days before declaringWait at least 5 days before declaring low chance for recoverylow chance for recovery
    42. 42. 47-year-old woman with a history of atrial fibrillation, recently started on dofetilide, who suffered a VF arrest while a passenger in a car on April 5th 2011. PEA on ED arrival, 45 min of CPR; Therapeutic hypothermia. Shock, acute renal failure treated with dialysis, and severe anoxic brain injury. April 11 No response to commands. GCS 5. Multisystem organ failure. “Cardiac arrest and anoxic encephalopathy. Her chance of recovery is becoming very small. We discussed her situation with her husband. “ April 13 (8 days after arrest). Still comatose. “We had a long discussion with her family, including review of her decreasing likelihood of good recovery, and what she would want us to do under that circumstance. “
    43. 43. Stacy Lee training CPR with Monique Anderson http://vimeo.com/43503123
    44. 44. OpportunitiesOpportunities  Systematic approach to train hands-only CPRSystematic approach to train hands-only CPR  Schools, health systems, local governments,Schools, health systems, local governments, businesses, community eventsbusinesses, community events  Improve dispatch performanceImprove dispatch performance  Improve EMS (first responder and paramedic) CPRImprove EMS (first responder and paramedic) CPR qualityquality  Hospital care: primary PCI, temperature control,Hospital care: primary PCI, temperature control, prognosticationprognostication  Measure, feedback, improveMeasure, feedback, improve
    45. 45. Thanks toThanks to  American Heart Association/ Mission: LifelineAmerican Heart Association/ Mission: Lifeline  Heart Rescue/ Medtronic FoundationHeart Rescue/ Medtronic Foundation  RACE Program including 120 hospitals and 640RACE Program including 120 hospitals and 640 EMS agencies in North CarolinaEMS agencies in North Carolina
    46. 46. extrasextras
    47. 47. What are the implications of the two hypothermiaWhat are the implications of the two hypothermia trials in 2013 for North Carolina and the RACE-ERtrials in 2013 for North Carolina and the RACE-ER Heart Rescue project?Heart Rescue project?  Continue to use in-hospital hypothermia and temperature control using hypothermia devices with automatic temperature control, especially for patients with ventricular fibrillation arrest. This has been a key part of a strategy now proven to improve survival from 25% in years past to over 50% now for patients who have hypothermia applied. Guidelines call for this as the highest, class I, recommendation.  Our interpretation of the prehospital trial is that it remains reasonable for agencies currently using prehospital hypothermia to continue it, and it is reasonable for agencies that have not used hypothermia or who need to direct resources elsewhere to forgo prehospital hypothermia. 1. Nielsen N et al. N Engl J Med 2013;369:2197-206 2. Kim F et. al. JAMA 2013

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