Pre Hospital Resuscitation


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  • My apologies for not knowing the real figures.
    I have visited USA Today (Six Minutes To Live or Die) and really amazed on what have been happening in places like Seattle. For example, I quote from USA Today:

    'Over time, Seattle has learned that more victims of cardiac arrest survive if a bystander intervenes and performs CPR, buying the person time until a defibrillator can be applied. So Seattle's emergency medical system, called Medic One, pushes CPR training and makes citizens partners.

    The city has trained ordinary citizens — from taxi drivers to restaurant employees — in CPR, making them members of what is known as Medic Two. Seattle firefighters work as instructors for the program and teach about 18,000 people a year. Since 1971, the city has trained 650,000 people. As a result, Seattle now has one of the highest 'bystander CPR' rates in the nation — 44%. That means that nearly half of all cardiac arrest victims get CPR from a co-worker, a loved one or a stranger in the minutes between collapse and when emergency medical crews arrive.

    'Seattle showed us it could be done,' says Rich Serino, Boston's emergency medical services chief. So Boston launched its own effort to involve citizens in saving lives, offering CPR training to individuals, churches, clubs and anyone who requested it. Menino used his clout as mayor to help EMS forge a partnership with local businesses. The city asked businesses to prepare to react to a cardiac arrest on their premises by having a defibrillator on hand and by having people trained to use it and to perform CPR.

    As a result, Boston's bystander CPR rate is 30%; that is, bystanders are already performing CPR when rescue crews arrive 30% of the time. The city has saved an additional 200 lives over the past 10 years with a public training program conducted by the fire department that cost $65,000 last year and is expected to cost nothing next year...'

    For us in Malaysia, I think, we need to have a coordinating body - a resuscitation council, etc - consisting on emergency physicians, cardiologist, public health educators, etc... up until someone up there (a policy maker, somebody powerful enough) is sensitive and passionate enough to mobilize such a nationwide scale of campaign, I am not sure how much we can increase the awareness, the knowledge as well as the skills of bystander CPR among the public; that's why I see the effort by National Heart Institute as a positive move to be lauded; yet we need to get the latest message across especially in instilling chest compression alone CPR.

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  • Big note: While most US cities have a ROSC rate of 1-5 % , a few cities ROSC approach 20-40%, namely Seattle/King County Medic One, Boston EMS, Austn Travis County EMS, and Ada County Paramedics. Thier approach is to limit the number of paramedics, but only send them on lifethreatening calls ( a different approach than most US cities) and really push rapid BLS over rapid ALS.

    I suggest you read the USA today series '6 minutes to live or die'.
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  • Pre Hospital Resuscitation

    1. 1. Pre-hospital Resuscitation K.S. Chew School of Medical Sciences, Universiti Sains Malaysia What’s new after “Guidelines 2005”?
    2. 2. Introduction (Cummins et al. 1991) Chain of Survival Early ALS Early Defibrillation Early CPR Early Recognition and Activation of EMS
    3. 4. What This Talk IS NOT <ul><li>IS NOT a cut and paste lecture from AHA/ILCOR Guidelines 2005 </li></ul><ul><li>IS NOT a description about the Malaysian prehospital scenario per se </li></ul><ul><li>IS NOT a critical appraisal on scientific articles </li></ul>
    4. 5. Another piece of evidence? But…does it fit??
    5. 6. Four Main Key Points
    6. 7. Key Point No. 1 <ul><li>We have good news – we are now back to a single emergency number 999 </li></ul><ul><li>But will the implementation be translated to an improved, effective prehospital communication? </li></ul><ul><li>Prank calls </li></ul><ul><li>Multilingual? </li></ul>
    7. 8. <ul><li>Chest compression only CPR (without mouth to mouth ventilation) is set to become more important in the out of hospital setting </li></ul><ul><li>That is a good news to us, especially in our cultural setting </li></ul>Key Point No. 2
    8. 9. Key Point No. 3 <ul><li>Energy levels in biphasic waveform defibrillator is becoming more definite in the very near future – it seems that higher energy (200J- 300J - 360J) is associated with better outcome if more than one shock required </li></ul><ul><li>Monophasic waveform is phasing out </li></ul>
    9. 10. Key Point No. 4 <ul><li>New evidence has shown that for certain cases of cardiac arrest patients who collapsed in the out of hospital setting, paramedics can terminate the resuscitation effort (even at BLS level only) because the survival rate is very very low. </li></ul><ul><li>Can this rule be applied in Malaysia? </li></ul>
    10. 11. Early Recognition
    11. 12. Early Recognition <ul><li>About three-quarters of out-of-hospital cardiac arrests occur at home or private residences rather than in public places </li></ul><ul><ul><li>Iwami et al. , (2006) Resuscitation 69, 221-228 </li></ul></ul>
    12. 13. Are We Targeting Enough? <ul><li>Bystander-initiated CPR most frequently takes place in public places such as the street (Herlitz et al. , 1994) </li></ul><ul><li>How about the majority (up to 75%) of the cases of cardiac arrest that occur at home? </li></ul>
    13. 14. Early Activation of EMS
    14. 15. 991 – Civil Defense Dept; 994 – Fire and Rescue By January 2008, all calls to 991 and 994 will be re-routed back to the 999 emergency call center
    15. 16. Prank Calls In 2006, 98.9% of all emergency calls received turned out to be prank calls Section 233, Communications and Multimedia Act 1998 - the penalty for misuse RM50 000 fine, and/or one year's jail The STAR, 25 th October 2007
    16. 17. Early CPR
    17. 18. AHA/ILCOR Guidelines 2005 <ul><li>Guidelines 2000 </li></ul><ul><li>15:2 for adults </li></ul><ul><li>5:1 for child </li></ul><ul><li>Guidelines 2005 </li></ul><ul><li>One universal ratio 30:2 for ALL except neonates </li></ul><ul><li>Simplify CPR for learning </li></ul><ul><li>Longer series of uninterrupted chest compressions. </li></ul>
    18. 19. Chest Compression Only CPR <ul><li>Guidelines 2005: </li></ul><ul><li>“… .. encouraged to do compression-only CPR if they are unable or unwilling to provide rescue breaths (Class IIa), although the best method of CPR is compressions ….. with ventilations .” </li></ul>
    19. 21. Mouth To Mouth Breathing <ul><li>The kiss of life or the barrier to CPR? </li></ul><ul><li>Bystander CPR only performed in less than 1/3 rd of out of hospital cardiac arrests </li></ul><ul><li>Complicated technique </li></ul><ul><li>Fear of transmission disease </li></ul><ul><li>Cultural barrier in Malaysia </li></ul>
    20. 22. SOS-KANTO Study <ul><li>Prospective, multicenter, observational </li></ul><ul><li>In Kanto region of Japan </li></ul><ul><li>Witnessed, out of hospital cardiac arrest </li></ul><ul><li>Primary endpoint - favourable neurological outcomes at 30 days after cardiac arrest </li></ul><ul><li>Secondary endpoint – survival 30 days after cardiac arrest </li></ul>
    21. 23. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet 2007; 369 (9565):920-6.
    22. 24. Lancet 2007; 369 (9565):920-6 72% 18% 11%
    23. 25. Key Findings of SOS-KANTO Study <ul><li>Out of the 4068 adults who had out-of-hospital cardiac arrests: </li></ul><ul><ul><li>72% did not receive CPR from a bystander </li></ul></ul><ul><ul><li>18% received full CPR from a bystander, and </li></ul></ul><ul><ul><li>11% received chest compression alone from a bystander </li></ul></ul><ul><li>Any resuscitation is better than no resuscitation at all (in terms of favourable neurological outcome at 30 days) [5% vs 2%, p<0.0001] </li></ul>
    24. 26. <ul><li>Chest compression only is better than chest compression PLUS mouth to mouth in these THREE subgroups of patients: </li></ul><ul><ul><li>Those with apnea [6% vs 3% (p=0.0195)] </li></ul></ul><ul><ul><li>Those with a shockable rhythm [19% vs 11% (p=0.041)] </li></ul></ul><ul><ul><li>Those who received CPR within 4 minutes [10% vs 5% (p=0.0221)] </li></ul></ul><ul><li>NO subgroup showed any benefit from the addition of mouth to mouth breathing </li></ul>Key Findings of SOS-KANTO Study
    25. 28. Why Chest Compression Alone is Preferred for Bystander CPR? <ul><li>Advantages to the rescuer </li></ul><ul><li>Simplify technique </li></ul><ul><li>More willing to perform </li></ul><ul><li>Advantages to the patients </li></ul><ul><li>Less interruptions of essential chest compression </li></ul><ul><li>Mouth-to-mouth may actually increase intrathoracic pressure and reduce venous return </li></ul><ul><li>Ventilation maybe unnecessary especially during initial stage when the oxygen tension is still adequate </li></ul>
    26. 29. Prompt Guidelines Revision? <ul><li>“ This finding (SOS-KANTO’s) is an important piece of evidence that should lead to a prompt interim revision of the guidelines for out-of-hospital cardiac arrest. Eliminating the need for mouth-to-mouth ventilation will dramatically increase the occurrence of bystander-initiated resuscitation efforts and will increase survival.” </li></ul><ul><ul><li>(Ewy 2007, in an editorial comment in Lancet) </li></ul></ul>
    27. 30. A Blanket Rule Doesn’t Apply <ul><li>“ We should, for now, to follow the newer guidelines [guidelines 2005] of assisted ventilations and chest compression [meaning ratio 30:2 ] for respiratory arrest (such as in drowning and drug overdose), but the guidelines should promptly be changed to chest-compression alone for witnessed unexpected sudden collapse…” </li></ul><ul><ul><li>(Ewy 2007, in an editorial comment in Lancet) </li></ul></ul>
    28. 31. Ultimately our aim is to get more public member to perform bystander CPR!!! Not just knowing.. but willing
    29. 32. <ul><li>SOS-KANTO’s findings - a good news to us </li></ul><ul><li>Encourage more public , not just to know, but also to be ready and willing to perform bystander CPR </li></ul><ul><li>IF steps simplified (chest compression only) – knowledge can also be disseminated to more public members – e.g. through short documentary clips in TV, etc </li></ul>The Challenges within the Malaysian Context
    30. 33. SOS-KANTO Study
    31. 34. Early Defibrillation
    32. 35. AHA/ILCOR Guidelines 2005 <ul><li>“ The optimal energy for first-shock biphasic waveform defibrillation … has not been determined” </li></ul><ul><li>“ Multiple .. studies have failed to identify an optimal biphasic energy level for first or subsequent shocks. Therefore, it is not possible to make a definitive recommendations for the selected energy for first or subsequent biphasic defibrillation attempts.” </li></ul>
    33. 36. Introduction: BIPHASIC Trial (Stiell et al. 2007)
    34. 37. BIPHASIC Trial <ul><li>Triple blinded (blinded to researcher, patient and healthcare provider) </li></ul><ul><li>Randomized, Multicenter, Manufacturer-funded </li></ul><ul><li>Compare fixed lower energy (150J-150J-150J) or escalating higher energy level (200J-300J-360J) </li></ul><ul><li>Primary outcome – successful conversion to an organized rhythm </li></ul><ul><li>Secondary outcome – termination of VF/pulseless VT regardless of the post-shock rhythm </li></ul>
    35. 38. BIPHASIC Trial
    36. 39. BIPHASIC Trial If only a single shock is required, NO DIFFERENCE either using a lower or higher energy level
    37. 40. BIPHASIC Trial When multiple shock required, then higher energy escalating level is better
    38. 41. Implications of BIPHASIC Trial <ul><li>AHA/ILCOR Guidelines 2005 clearly states that three stacked shocks are no longer recommended (as per Guidelines 2000) </li></ul><ul><li>Rather, the Guidelines 2005 recommend a high, single shock followed immediately by resuming chest compression </li></ul><ul><li>This is to minimize delay in chest compression </li></ul>
    39. 42. <ul><li>This study implies that if fixed lower energy regimen is chosen, many patients probably were still in VF while CPR is going on </li></ul><ul><li>Which means that there will be a need for additional shocks; thus causing interruptions in chest compression </li></ul><ul><li>This seems to go against the recommendation of AHA/ILCOR Guidelines 2005 of a single shock in minimizing interruption?? </li></ul>Implications of BIPHASIC Trial
    40. 43. Back to square one?
    41. 44. Question we may need to answer in the future is Should we start with ONE, SINGLE, HIGHEST energy level for biphasic waveform? And what is that level of energy?
    42. 45. Early ALS
    43. 47. Let’s Face the Reality! <ul><li>Generally, the survival rate after a out of hospital cardiac arrest is extremely low - <5%! </li></ul><ul><li>There is no evidence that these rates are increasing, despite extensive use of advanced treatments and technology </li></ul><ul><ul><li>(Vaillancourt and Stiell, 2004) </li></ul></ul><ul><li>Even in large cities in US, the overall survival has been quoted as ~1% </li></ul><ul><ul><li>(Ewy 2006) </li></ul></ul>
    44. 48. Which Patients Should Be Transported Back? <ul><li>“ ..resuscitation attempts should be terminated when the patient remains in asystole despite full advanced life support procedures for more than 20 minutes ” </li></ul><ul><ul><li>Recognition of Life Extinct (ROLE) Guidelines by the Joint Royal Colleges Ambulance Liason Committee </li></ul></ul><ul><li>Then how about those with only basic life support measures given by the paramedics and EMTs with the use of AEDs? </li></ul>
    45. 49. Termination of Resuscitation (TOR) Study <ul><li>In NEJM 2006, Morrison et al reported their prospective validation of their previously published TOR clinical prediction rule (developed in 2002) that was derived retrospectively. </li></ul><ul><ul><li>Morrison LJ, Visentin LM, Kiss A et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2006; 355 (5):478-87. </li></ul></ul>
    46. 51. TOR Prediction rule <ul><li>Termination of BLS resuscitation should be considered when </li></ul><ul><li>There was no ROSC at all before transport </li></ul><ul><li>No shocks indicated/given before transport </li></ul><ul><li>It was not witnessed by the EMS personnel </li></ul><ul><li>The authors found that only 0.5% of patients survived if all THREE criteria are present </li></ul>
    47. 52. <ul><li>Out of the 1240 patients, 776 patients fulfilled criteria to apply the TOR rule. </li></ul><ul><li>Out of this 776 patients, only 4 survived (0.5%) </li></ul><ul><li>Positive Predictive value 99.5% </li></ul><ul><li>Specificity 90.2% </li></ul>TOR Prediction rule
    48. 53. Results
    49. 54. Disadvantages Of Transporting Refractory Cardiac Arrests <ul><li>Limits availability of EMS personnel </li></ul><ul><li>Increasing patient’s waiting time </li></ul><ul><li>Decreases availability of bed </li></ul><ul><li>Emergency lights and siren by ambulance driver – pose risks to motorists, pedestrian, etc </li></ul><ul><li>EMS personnel performing interventions in a moving vehicle or engaged in resuscitation are at increased occupational biohazards risk </li></ul>
    50. 55. Wasting Of Resources In Transporting A so called “Futile” Cardiac Arrest Case? REALLY???
    51. 56. Guidelines remain Guidelines <ul><li>“ In an editorial published more than 20 years ago, Cummins and Eisenberg suggested that prediction rules for the termination of resuscitation efforts should remain advisory and that they should be tempered by the clinical picture, taking into account the very small possibility of successful resuscitation when the prediction rules suggest termination” </li></ul><ul><ul><li>(Morrison et al. 2006) </li></ul></ul>
    52. 57. Can Our Paramedics Be Reliably Depended Upon To Terminate Resuscitation and sending the patient to mortuary? … or even to start resuscitation?
    53. 58. Can TOR guidelines be applied in Malaysia? <ul><li>Yes and no </li></ul><ul><li>Issues yet to be resolved: </li></ul><ul><li>For how long BLS continued before we call it off as no ROSC achieved? </li></ul><ul><li>Who are in the ambulance? Any doctor? </li></ul><ul><li>Legal right/authority of paramedics to declare death </li></ul>
    54. 59. Conclusion
    55. 60. What Would The Future Be In The Area Of Pre-hospital Resuscitation ? Within the Malaysian context?
    56. 61. Looking At Things From Different Angles Improving ambulance response time Upgrading paramedics status Educating the public regarding CPR through campaign in mass media Purchasing new equipments – airway gadgets, CPR devices, etc Organize more BLS course A single universal access number Simplify the technique of effective CPR Placing more AEDs in public
    57. 62. Conclusion <ul><li>Many more studies on chest compression alone bystander CPR expected to follow after SOS-KANTO study </li></ul><ul><li>Chest compression alone CPR set to become more important in the out of hospital setting; more definite indications in the future </li></ul>
    58. 63. Conclusion <ul><li>Energy regimen for biphasic waveform defibrillator? </li></ul><ul><li>Energy levels in biphasic waveform defibrillator set to become more definite in the very near future </li></ul><ul><li>Monophasic waveform is phasing out </li></ul><ul><li>More manufacturers will reconfigure the energy level regiment in their AED product </li></ul>
    59. 64. Termination of resuscitation in the field? That I am not so sure! Most probably still a long way ahead
    60. 65. A Tale of Our Very Own
    61. 66. References <ul><li>Cummins RO, Ornato JP, Thies WH et al. Improving survival from sudden cardiac arrest: the &quot;chain of survival&quot; concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991; 83 (5):1832-47. </li></ul><ul><li>Ewy GA. Cardiac arrest--guideline changes urgently needed. Lancet 2007; 369 (9565):882-4. </li></ul>
    62. 67. <ul><li>Stiell IG, Walker RG, Nesbitt LP et al. BIPHASIC Trial: a randomized comparison of fixed lower versus escalating higher energy levels for defibrillation in out-of-hospital cardiac arrest. Circulation 2007; 115 (12):1511-7. </li></ul><ul><li>2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005; 112 (24 Suppl):IV1-203. </li></ul>References
    63. 68. References <ul><li>Ewy GA. Cardiac resuscitation--when is enough enough? N Engl J Med 2006; 355 (5):510-2. </li></ul><ul><li>Morrison LJ, Visentin LM, Kiss A et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2006; 355 (5):478-87. </li></ul>
    64. 69. Visit or