This document discusses improving cardiac resuscitation systems of care. It describes how some systems achieve survival rates over 50% for cardiac arrests due to ventricular fibrillation through coordinated efforts including bystander CPR, public access defibrillators, EMS response times, and post-resuscitation care. The document outlines key components of model systems including establishing registries to measure performance, improving layperson and EMS involvement in CPR, and decreasing time to access emergency care. It emphasizes that the overall system of care, not individual components, determines survival rates.
In this American Physiological Society (APS) webinar produced in partnership with ADInstruments, DeWayne Townsend, DVM, PhD and Adam Goodwill, PhD discuss how to collect and analyze quality pressure-volume loop data.
Specifically, they discuss why PV loops are considered the gold standard for measuring cardiac function in vivo, what equipment is required to collect PV loop data, and how to minimize variability in your data. The focus of the webinar is on data analysis – DeWayne and Adam demonstrate how to analyze load-independent measures of function and discuss what the data mean.
Key Learning Objectives Include:
– Why PV loops? What are the alternatives (e.g. echo, MRI, etc.) and how do PV loops compare?
– Why is the Starling effect important?
– Load independent measures: what are they and how are they measured? How are data analyzed and what do they mean?
– Equipment basics: what do you need to record PV loop data?
– What causes variability and how do you mitigate it?
Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.
2014 importance of cpr eastern or ems conferenceRobert Cole
Updated importance of CPR lecture I gave for the Eastern OR EMS Conference
http://easternoregonems.com/
Facebook Page: https://www.facebook.com/EasternOREMS?ref=br_tf
In this American Physiological Society (APS) webinar produced in partnership with ADInstruments, DeWayne Townsend, DVM, PhD and Adam Goodwill, PhD discuss how to collect and analyze quality pressure-volume loop data.
Specifically, they discuss why PV loops are considered the gold standard for measuring cardiac function in vivo, what equipment is required to collect PV loop data, and how to minimize variability in your data. The focus of the webinar is on data analysis – DeWayne and Adam demonstrate how to analyze load-independent measures of function and discuss what the data mean.
Key Learning Objectives Include:
– Why PV loops? What are the alternatives (e.g. echo, MRI, etc.) and how do PV loops compare?
– Why is the Starling effect important?
– Load independent measures: what are they and how are they measured? How are data analyzed and what do they mean?
– Equipment basics: what do you need to record PV loop data?
– What causes variability and how do you mitigate it?
Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.
2014 importance of cpr eastern or ems conferenceRobert Cole
Updated importance of CPR lecture I gave for the Eastern OR EMS Conference
http://easternoregonems.com/
Facebook Page: https://www.facebook.com/EasternOREMS?ref=br_tf
This is a slightly updated version of a previous lecture on the science behind CPR. I have deleted the older version to avoid confusion, though they are both essentially the same
This lecture is good for first responders of all levels (from lifegaurds to paramedics) to really bring home the importance of CPR. It has been my experiance that current CPR classess are lacking in this regard, therefore compliance with new CPR standards is lacking, and this promotes LAZY CPR. This is my attempt to remedy that issue.
if a person sudely collapses in front of you. what should we do?
immediately we should assess for cadiac arrest.
if so, immediately we should start high quality CPR.
This slide focuses on how to assess for cardiac arrest and how to do CPR.
In critical moments where every second counts, the knowledge and skills to perform Adult Cardio Pulmonary Resuscitation (CPR) can make the difference between life and irreversible damage. This comprehensive presentation, titled "Adult CPR Techniques: A Comprehensive Guide (BLS-ACLS-Post CPR)," available on SlideShare, delves into the intricacies of adult CPR, offering a well-rounded overview of Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), and the crucial post-CPR procedures.
The presentation is meticulously designed to cater to healthcare professionals, first responders, and individuals seeking a comprehensive understanding of adult CPR techniques. Starting with the fundamental principles of BLS, the slides explore step-by-step instructions for delivering effective chest compressions and rescue breaths. The integration of up-to-date guidelines ensures that viewers are equipped with the most accurate and evidence-based practices.
Transitioning into the realm of ACLS, the presentation delves into the advanced interventions necessary for managing cardiac arrest situations. Topics such as defibrillation, drug administration, and airway management are covered in depth, empowering viewers to make informed decisions and take appropriate actions during critical moments.
Furthermore, the post-CPR segment of the presentation highlights the essential steps to follow once successful resuscitation has occurred. From monitoring vital signs to providing appropriate care, this section addresses the critical period following CPR and emphasizes the significance of ongoing support and medical attention.
The presentation employs a blend of engaging visuals, explanatory diagrams, and succinct textual content to facilitate a holistic learning experience. Whether you're a medical professional aiming to refresh your skills, a student delving into life-saving techniques, or an individual concerned with being prepared for emergencies, this slide deck offers an invaluable resource for acquiring and reinforcing essential knowledge.
In summary, "Adult CPR Techniques: A Comprehensive Guide (BLS-ACLS-Post CPR)" is a comprehensive SlideShare presentation that meticulously covers the entire spectrum of adult CPR, ranging from Basic Life Support and Advanced Cardiovascular Life Support techniques to vital post-CPR considerations. By exploring this presentation, you'll be better equipped to respond effectively to cardiac emergencies and contribute to saving lives within your community.
Death from Sudden Cardiac Arrest is a Preventable Crime! What is the Role of ...David Hiltz
Law Enforcement is in a strategic position to help reduce the number of victims from cardiac arrest.
In this document best practices are outlined.
10 recommendations mutually agreed upon by IACP and the IAFC.
Citizen CPR Foundation Cardiac Arrest Survival Summit 2021: A Call for Presen...David Hiltz
What innovative ideas or compelling points of view do
you have to share with other professionals in the field of
resuscitation? We encourage you to take part in the
2021 Cardiac Arrest Survival Summit by submitting a
presentation or poster submission.
With your contribution to the program, the Summit will
continue to deliver action-oriented programs and
dynamic new content that brings our global community
together to Reconnect & Recharge by strengthening
connections and communities to save more lives.
Effect of Optimized Versus Guidelines‐Based AED Placement on Out‐of‐Hospital ...David Hiltz
Effect of Optimized Versus Guidelines‐Based AED Placement on Out‐of‐Hospital Cardiac Arrest Coverage: An In Silico Trial.
Our special guests are Christopher Sun, a Postdoctoral Fellow at Massachusetts Institute of Technology’s Sloan School of Management and Massachusetts General Hospital and Timothy Chan, Canada Research Chair in Novel Optimization and Analytics at the University of Toronto who will join us to talk about their recently published research.
Study reference:
https://www.ahajournals.org/doi/10.1161/JAHA.120.016701
WHY COMMUNITIES NEED AN ORGANIZED STRATEGY TO IMPROVE CARDIAC ARREST OUTCOMESDavid Hiltz
Looking to promote HEARTSafe in your community? These slides may help!
For annotated slides with notes, contact the Citizen CPR Foundation HEARTSafe Program Director david@code1web.com
Improving Access to Automated External Defibrillators -Free WebinarDavid Hiltz
Improving Access to Automated External Defibrillators
A FREE webinar hosted by Code One Training Solutions and AED Team.
Friday March 27th from 2:00 PM to 3:00 PM EST
Register Here: https://codeone.enrollware.com/enroll?id=3709808
Although many of our public spaces, schools and venues have AEDs, they are not always available.When a person suffers cardiac arrest, there is a one in five chance a potentially life-saving Automated External Defibrillator (AED) is nearby. But up to 30 per cent of the time, the device is locked inside a closed building, according to a study led by U of T Engineering researchers, published in the Journal of the American College of Cardiology. https://www.utoronto.ca/news/life-saving-defibrillators-often-behind-locked-doors-during-hours-says-u-t-study
Learn how AEDs are being made accessible on a 24/7 basis using weatherproof outdoor enclosures.
HEARTSAFE Community Launch- Cardiac Arrest Survival SummitDavid Hiltz
Building communities of heroes and survivors by improving action and response to cardiac arrest through training, preparation and response protocols.
https://citizencpr.org/heartsafe/
Resuscitation is a "team sport"! Plan to attend the Resuscitation Ocer Program with your institutional peers and learn from
the course faculty as well as from other participants through facilitated and interactive exercises. This course is offered as a
pre-conference workshop in conjunction with the Cardiac Arrest Survival Summit, presented by the Citizen CPR
Foundation.
This dynamic 8-hour certificate program is designed to prepare physicians, nurses and allied healthcare professionals to
effectively organize and implement cardiac arrest guidelines, innovations and best practices to improve outcomes from
cardiac arrests that occur in the hospital setting.
Focus areas include:
• Code committee and code team organization
• Process improvement
• Emergency ultrasound
• Targeted temperature management
• Post resuscitation PCI
• ECMO
• High-quality training
• Mock codes
• Comprehensive CQI and more
The Citizen CPR Foundation is proud to present this course as part of the Cardiac Arrest Survival Summit, December 10-13,
2019, and other pre-conference workshops happening the 9th and 10th. Formerly ECCU, the Summit is the largest and most
well-respected conference on cardiac arrest care for CPR and ECC instructors, nurse & hospital educators, researchers, EMS
and PAD program managers, EMS medical directors and survivors.
Learn more and register for the ROP course or for the Summit in its entirety by visiting citizencpr.org/summit. We look
forward to meeting you there.
The Journal of Collegiate Emergency Medical Services (JCEMS) and
NCEMSF are proud to host the Academic Poster Session at the
25th Annual Conference.
Abstracts for poster presentations are encouraged from students
and professionals on (1) original research or (2) the development
and evaluation of novel initiatives and programs. Topics include:
• Pre-hospital patient care
• Operations, communications, and equipment
• Training and education
• Administration and agency development
• Career and alumni resources
• Campus public health and safety
Authors of accepted abstracts will present posters at a 1-hour
academic poster session.
All accepted abstracts will be published in JCEMS.
Submission Guidelines
Deadline:
January 15, 2018
For details, please review the Poster
Abstract Submission Guide at:
www.ncemsf.org/conference/2018-conference
Review and Selection
Abstracts will be reviewed and selected
by the JCEMS Editorial Board.
Independent reviewers with subjectmatter
expertise may also review
submissions.
Conference Details
Details available at:
www.ncemsf.org/conference/2018-conference
Improving Bystander CPR, Community Mobilization and Outreach Using Media Infl...David Hiltz
All of you sitting out there have great stories to tell. Stories that will save lives. And news organizations want them.
You just need to figure out how to get the stories out in your communities and better yet, how to get the news organizations to get them out for you. Because the holy grail of any public relations effort, any educational effort, that aims to reach a mass audience through mass media is a staff written story.
And changes in the news industry that are challenging newsrooms across the country are in your favor.
My comments are based on a working knowledge of small, community news organizations, not the big guys, but I believe the same holds true them as well.
It’s no secret that the number of reporters and photographers and editors in traditional newsrooms is shrinking. But news editors still have holes to fill in print editions and they face a constant challenge to keep their websites updated with new information 24/7.
Those challenges are your entryway.
But you won’t gain entry without your own challenges. Those tight staffing situations may make your mission harder at the outset than it might have been 10 or 20 years ago when newsrooms were flush with young reporters looking for their next story.
You’ve got to get a reporter or editor to take the time to listen to you and they’re all wearing several hats taking care of print issues and web site updates and social media posts. So be politely persistent.
David Hiltz was and he ended up getting more than one message into our paper and on our web site. If I may, I suggest you borrow a line from David. After challenging him to tell me why we should be writing about this stuff as a general circulation newspaper and website rather than a medical journal, he had the perfect line.
“If 15-20 people were needlessly dying in house fires in Westerly each year, would that be newsworthy," he asked. "How is cardiac arrest any different?"
Perseverance will be key, but if you get your pitch down right -- make it brief, but compelling – you should be able to convince an assignment editor that you’ve got a story that will get lots of eyeballs on his or her website -- and maybe even convince someone to grab a print copy off the rack.
Local and unique are the keys to good news stories in 2017 when global news is available from any number of news outlets as soon as you grab you smartphone in the morning. And all of you have unique, local stories from your communities. Stories about regular citizens saving lives on the street because they learned how to do CPR or because they learned how to use an AED.
Access Denied! Failures in Automated External Defibrillator DeploymentDavid Hiltz
This presentation will examine current practices in early defibrillation strategies including defibrillation by law enforcement and PAD models. While millions of defibrillators have been placed in public venues, many victims are not defibrillated in a timely fashion.
Why do current practices fall short of expectations?
Strive to Revive! Translating Science to Survival The HEARTSafe Community Co...David Hiltz
Often it "takes a village" and indeed the entire community to make a significant difference! Hear how the HEARTSafe Community concept is designed to promote survival from sudden out-of-hospital cardiac arrest by recognizing and stimulating efforts by individual communities to improve their cardiac arrest system of care.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
1. PAVING THE WAY FOR A
STRONGER
RESUSCITATION SYSTEM
OF CARE
2. Though the national survival rate for cardiac arrest is in
the single digits, some systems are able to achieve a
survival rate of 50% or higher from cardiac arrest
associated with ventricular fibrillation – the rhythm with
the best chance of resuscitation.
How these systems do it, and how your system can do
it, is what the next 75 minutes are all about.
10. Why Such Variability in Survival
?
• In large part, due to
differences in the system of
care
– Incidence of bystander CPR
– Dispatch CPR instructions
– Community AED’s
– Timely EMS response
– Specific community practices for
activation of 911
• The SYSTEM of care
surrounding OHCA may have
some responsibility for the
survivability
Baker et all Resuscitation, 2008
11. Let’s Think About the Pieces of the System
Prehospital
• Early Access to 911
• Layperson training in CPR
• Public Access Defibrillator (PAD)
programs
• EMD assisted chest compressions
• First responder defibrillation – BLS
• ACLS
In-Hospital
• Early, goal directed therapy
• Therapeutic hypothermia
• Early PCI
• Implantable Cardiac Defibrillators
12. The EMS Side:
Save A Life – Restore Spontaneous Circulation #1
EVERYTHING we do should promote
forward flow of blood
ANYTHING that interrupts forward blood
flow should be critically evaluated
13. Model EMS System of Care #1
1. Establish a Registry
– Measure your starting point
2. Improve Layperson Involvement
– Layperson Chest Compression Training
– Implement Dispatcher Assisted CPR
3. Improve EMS Performance
– Implement High Performance CPR/CCR
4. Decrease Time to Patient Access
– Implement Rapid Dispatch
14. Model EMS System of Care #2
5. Voice Record All Resuscitations
6. Police (early) Defibrillation
7. Establish Public Access Defibrillation Program
8. Supplemental Funding and Support for Training and QI
9. Work Toward A Culture of Excellence
15.
16.
17.
18. 15 ISSUES IN RESUSCITATION
QUALITY
THAT FRACTURE
THE CHAIN OF
SURVIVAL
HILTZ
20. 1. TABLE 2 FROM PREVIOUS
SLIDE
2. IGNORING THE ISSUES
WON’T MAKE THEM GO
AWAY
3. CAN’T IMPROVE IT IF WE
ARE NOT MEASURING IT
4. DELAYS/INTERRUPTIONS
ARE REAL KILLERS
5. IT TAKES A SYSTEM TO
SAVE A LIFE
22. TIME IS ALL
• Life is measured in years, death is
eternal, the difference between
them is 10 minutes.
• Brain death occurs w/in 8 -10
minutes following collapse.
23. Why Is Time So Important in the Success of CPR ?
• There is no blood flow to the heart and brain, the 2 critical
organs. Without blood flow there is no oxygen exchange or
energy transfer .
• Cardiac arrest is the ultimate time sensitive medical condition.
• Ca.
• Cardiac arrest is the ultimate time sensitive
24. Cummins RO. Annals Emerg Med. 1989;18:1269-1275.
Resuscitation Success vs. Time
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8 9
%
Success
Time (minutes) after sudden cardiac arrest
Chance of successful resuscitation
falls 7 - 10% each minute
25. Time to Arrival of EMS
• In a recent retrospective article from North Carolina with 599
cardiac arrest patients every minute of delay in the arrival of
EMS led to a 8 % decrease in the likelihood of a shockable
rhythm. Again…7-10 % per minute.
26. Three-Phase Model of
Resuscitation
0 2 4 6 8 10 12 14 16 18 20
Arrest Time (min)
Circulatory
Phase
Electrical
Phase
Metabolic
Phase
0
100%
Myocardial ATP
Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8
27. The initial phase of a cardiac
arrest is responsive to
defibrillation. The response is very
time sensitive
28. Casinos and vf arrests
• Survival rate 74 % in patients who received first shock within 3
minutes
• Survival rate 49 % in patients who received first shock after 3
minutes
• Intervals of no more than 3 minutes from collapse to
defibrillation are necessary to achieve the highest survival
rates
29. Wouldn’t it be nice if we had a simple,
acceptable way to extend the electrical
phase of VF arrest ?
There is!
Perfuse the heart and it will continue to fibrillate
30. Prevalence of VF on arrival of EMS
in Out-of-Hospital Cardiac Arrest in Arizona
• Not witnessed 16%
• Witnessed but no bystander CPR 36%
• Witnessed and bystander CPR 52%
Data from 1,296 cardiac arrest in Arizona
Voluntary reporting SHARE Program
Data collected October 2004 to April 2006
Bobrow, Clark, Ewy, Kern, Sanders
31. So What if the Patient is Still in Vfib?
• Thus with chest compressions the cardiac arrest victims will be
far more likely to remain in ventricular fibrillation , and not
deteriorate into asystole . This is the key to higher rates of
survival following cardiac arrest.
• YOU WILL SUSPEND DEATH!!!
32. Importance of Continuous Chest Compressions
• Chest compression only CPR early in cardiac arrests is more effective than
is CPR that includes stopping to give breaths. The key is continuous
compressions and anything that interferes with chest compressions is
harmful.
• There is a rapid decline in survival without chest compressions. You die at a
rate of 10 % per minute without chest compressions.
33.
34.
35. Cardiac Output and Chest Compressions
• The previous slide reveals that with perfect CPR the best
cardiac output we can achieve is 15 %- 21 %. It is not very
much, but it is enough.
36. The Key
• Push hard [to 2 inches]
• Push Fast [100 per minute]
• Recoil [get your hands off]
• And
• Don’t Stop [for 2 minutes]
38. Deeper Sternal Displacement Improves
Blood Flow
Babbs. Ann Emerg Med. 1983;12:530.
Relative peak blood pressure and “cardiac output” in anesthetized dogs during CPR
cm of sternal displacement
39. Organ Blood Flow During Optimal Chest
Compression
0
10
20
30
40
50
60
70
80
90
100
Brain Heart Kidneys Intestine
Achievable blood
flow, percent of
normal
Typical flow in
humans during
CPR
Voorhees W. Crit Care Med 1980;8:134
Tissue flow in anesthetized dogs during optimal ventilation and chest compression.
40. • The deeper you compress the higher the cardiac output. The
key is 5 cm, 2 inches, even in children [the AHA states that in
children compressions should be 1/3 the AP diameter of the
chest approximately 2 inches!].
42. Higher Rate of Chest Compression
= Better Outcome
97 in-patients at 3 hospitals in Chicago, mostly in the ICU.
Abella B. Circulation. 2005;111:428-434.
Inpatient cardiac arrest patients at the University of Chicago
43. The Key on Rate
• The previous slide , from an ICU in Chicago , reveals 2 things , one is
that ROSC [return of circulation, and therefore survival ] is directly
related to the rate. The ROSC at a rate of 60 compressions per
minute is only ¼ as high as the rate of ROSC at 100 compressions
per minute.
• The other very important bit of data is that when the compression
rate exceeds 120 the rate of ROSC declines. You must maintain a
rate of 100.
45. During cardiac arrest, chest
compressions are the patient’s heart
beat
Therefore, one needs to assure near
continuous chest compressions!
46. Compression fraction and survival
• CPR Fraction 75% Odds Ratio 2.4
• 70% 3.4
• 65% 5.3
• 60% 7.9
• 55% 11.1
• With a compression fraction of >80 % survival is 11 times greater
than with a compression fraction of 55 %... The ration seen in the
study by Valenzuela . The typical fraction in arrests has been 60 %.
47. The Key [again]
• The previous slide makes it clear that the compression fraction ,
how continuous your chest compressions are, determine your
survival. If your compression fraction is >80 % your survival is 11
times more likely than with a compression fraction of 55 %
[essentially , you are compressing only half the time ]. This slide
basically shows a straight line of survival with the continuity of
chest compressions . DON’T STOP CHEST COMPRESSIONS. They are
the patients only heart beats.
48. Recoil
You must get your hands off
the chest as you do
compressions.
Where is the data?
49. Get Your Hands off the chest and ALLOW RECOIL
Blood flow to the coronary arteries only occurs in diastole. Diastole occurs
when the heart is relaxing and is finished with its compression. This
corresponds to when you let up from a chest compression, “RECOIL”. If you
maintain your hands on the chest during recoil there is inadequate blood
flow to the coronary arteries.
Blood flow to the brain [and the rest of the body] occurs when the heart
squeezes out blood during your chest compression.
THUS FOR GOOD BLOOD FLOW TO THE BRAIN AND THE HEART YOU
MUST DO A HARD CHEST COMPRESSION AND THEN ALLOW RECOIL.
50. Intubation and Cardiac Arrests in 2014
There is now compelling
laboratory and clinical data that
are persuasive for the proposal
that intubation be delayed for at
least 8 minutes in a cardiac
arrest.
52. • There is a lot of data that hyperventilation is harmful in cardiac
arrests. There is a lot of data that any interruption in chest
compressions is harmful. If intubation will be done , it must not
interrupt chest compressions and ventilation cannot be
allowed to be too frequent [the AHA recommends 6-8 per
minute] .
53.
54. TIME IS ALL
• Life is measured in years, death is
eternal, the difference between
them is 10 minutes.
• Brain death occurs w/in 8 -10
minutes following collapse.
64. Telecommunicator CPR
• Key to saving lives is quickly recognizing that a cardiac arrest
has occurred and to initiate Hands Only CPR in the shortest
possible time
65. TIME IS ALL
• Life is measured in years, death is
eternal, the difference between
them is 10 minutes.
• Cardiac Arrest is a critical, life-
threatening emergency!
• Brain death occurs w/in 8 -10
minutes following collapse.
66. Cummins RO. Annals Emerg Med. 1989;18:1269-1275.
Resuscitation Success vs. Time
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8 9
%
Success
Time (minutes) after sudden cardiac arrest
Chance of successful resuscitation
falls 7 - 10% each minute
67. Six Seconds
• That means that EVERY 6 seconds will KILL 1%
more people ! Think about that when you ask
more questions.
68. Why Is Time So Important in the Success of CPR ?
• There is no blood flow to the heart and brain, the 2
critical organs. Without blood flow there is no oxygen
exchange or energy transfer .
69. It is a Problem With the Heart!
• In cardiac arrest the heart stops pumping effectively. The lungs
are normal. There is no problem with oxygen. The problem is
cardiac and not pulmonary.
70. The Importance of Dispatch CPR
• In the first 5- 10 minutes of most cardiac arrests EMS is not
available . For the bystander who calls in the arrest the
dispatcher has the opportunity to provide instructions in CPR
that will prolong the ventricular fibrillation phase and allow
EMS to arrive with a high likelihood of a successful
resuscitation.
• WE WILL SAVE MORE LIVES.
71. MA State Law on Dispatch
The 911 service must have a Medical director.
The service must do Quality Assurance [Q/A ] on
its calls, and
it must offer dispatch CPR over the phone to callers.
I will offer some ideas on Q/A .
The state of Massachusetts follows the guidelines of the American
Heart Association [AHA ] . The AHA offers clear guidance on
Dispatch CPR. I will present their policy.
72.
73. AHA AND DISPATCH CPR
“CPR instructions for performing Hands
Only CPR enable the rescuer to start
compressions on average a minute sooner
than conventional CPR. “
“Delaying the initiation of chest
compressions while trying to determine
the precise cause of the arrest is
suboptimal”
74. AHA AND DISPATCH CPR
“ In nearly half of all cases in which
dispatchers provide CPR …instructions ,
the patient will not be in arrest. Serious
injury from bystander CPR is uncommon
[1-2%], but failure to provide bystander
CPR to people in cardiac arrest can be
lethal…
75. AHA AND DISPATCH CPR
• “The balance greatly favors beginning CPR whenever a
patient is determined to be unresponsive and not breathing
,OR NOT BREATHING NORMALLY.”
76. Why Does This Issue Matter?
• Multiple studies have shown that bystander initiated CPR will double or
triple the rate of survival from a cardiac arrest.
• The chance of survival decreases by 7-10 % for every minute that no CPR is
performed.
• With Hands Only CPR it is 2% per minute
• We must increase the number of people who will perform bystander CPR
• WE WILL SAVE MORE PEOPLE!
78. The Caller Interview
The Two Critical Questions:
• Is the patient conscious?
• Are they breathing normally?
If the answer to both questions is “no”, begin Hands-Only
CPR
80. Higher Rate of Chest Compression
= Better Outcome
97 in-patients at 3 hospitals in Chicago, mostly in the ICU.
Abella B. Circulation. 2005;111:428-434.
Inpatient cardiac arrest patients at the University of Chicago
81. Why not Mouth to Mouth Breathing in Adult CPR ?
• If someone tries to give M2M breathing to a patient with a
cardiac arrest the most compressions that can be given is 60
/per minute. Giving 30 compressions takes 15 seconds , giving
2 breaths takes approximately 15 seconds as well. A second
round of breaths and compressions adds up to 1 minute.
• Eliminating breathing and doing continuous compressions at a
rate of 100 /minute will quadruple the ROSC , compared to a
rate of 60!
83. QA Goals
• Recognition of a cardiac arrest in 75% of cases
• Recognition of the cardiac arrest within 1 minute,
followed by the start of compressions
• Provision of dispatcher assisted CPR on all cardiac arrest
calls treated by EMS, or the reason why it was not
given.
• Provide feedback to dispatchers
84. Review the following data for every Run
• Was the arrest recognized ?
• Were the 2 Key Questions asked?
• Were agonal respirations recognized [if present]?
• Was cardiac arrest recognized in under 1 minute?
• Were telephone CPR instructions offered, and accepted by the
bystander? Do not ask if the bystander is willing, instruct them
what to do, people are more likely to follow your instructions
when told what to do than when offered options.
85. Measurement of Critical Variables
• Witnessed?
• Time of collapse?
• Bystander CPR?
• Dispatcher CPR offered?
• Dispatch CPR performed?
• Time intervals?
86. Measurement of Outcomes
• In conjunction with EMS QI
• Was ROSC achieved at scene?
• Was ROSC achieved at the hospital?
• Discharged alive with good CPS score?
87. • Dispatcher is the most
important first responder
• Cardiac arrest can be difficult
to recognize
• Risk of injury from
unnecessary CPR is minimal
• Ask the 2 Key Questions
• Training and QA
89. Although technology, such as that
incorporated in automated external
defibrillators (AEDs), has contributed to
increased survival from cardiac arrest, no
initial intervention can be delivered to the
victim of cardiac arrest unless bystanders
are ready, willing, and able to act.
Moreover, to be successful, the actions of
bystanders and other care providers must
occur within a system that coordinates and
integrates each facet of care into a
comprehensive whole, focusing on survival to
discharge from the hospital.
90.
91. HIGH DOSE LOW FREQUENCY
VS.
LOW DOSE HIGH FREQUENCY?
102. Researchers at the University of
Copenhagen measured cardiac arrest
response in the city from 1994 to 2011.
During that period, there were 1,864
cardiac arrests in public areas. 30% of
victims collapsed within 100 meters of
an AED. However, of those AEDs, 53.4 %
were inaccessible during evening,
night, and weekend hours.
109. 1. REDUCING TIME TO SHOCK
2. AEDs DON’T SAVE PEOPLE…
PEOPLE SAVE PEOPLE
3. VALUE OF ERPs AND
REGISTRIES
4. TRUE OPEN ACCESS
5. IT TAKES A SYSTEM TO
SAVE A LIFE
111. Cummins RO. Annals Emerg Med. 1989;18:1269-1275.
Resuscitation Success vs. Time
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8 9
%
Success
Time (minutes) after sudden cardiac arrest
Chance of successful resuscitation
falls 7 - 10% each minute
112. Three-Phase Model of
Resuscitation
0 2 4 6 8 10 12 14 16 18 20
Arrest Time (min)
Circulatory
Phase
Electrical
Phase
Metabolic
Phase
0
100%
Myocardial ATP
Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8
113. The initial phase of a cardiac
arrest is responsive to
defibrillation. The response is very
time sensitive
114. Wouldn’t it be nice if we had a simple,
acceptable way to extend the electrical
phase of VF arrest ?
There is!
Perfuse the heart and it will continue to fibrillate
115. So What if the Patient is Still in Vfib?
• Thus with chest compressions the cardiac arrest victims will be
far more likely to remain in ventricular fibrillation , and not
deteriorate into asystole . This is the key to higher rates of
survival following cardiac arrest.
• YOU WILL SUSPEND DEATH!!!
116.
117. The Key
• Push hard [to 2 inches]
• Push Fast [100 per minute]
• Recoil [get your hands off]
• And
• Don’t Stop [for 2 minutes]
118. Higher Rate of Chest Compression
= Better Outcome
97 in-patients at 3 hospitals in Chicago, mostly in the ICU.
Abella B. Circulation. 2005;111:428-434.
Inpatient cardiac arrest patients at the University of Chicago
119. The Key on Rate
• The previous slide , from an ICU in Chicago , reveals 2 things , one is
that ROSC [return of circulation, and therefore survival ] is directly
related to the rate. The ROSC at a rate of 60 compressions per
minute is only ¼ as high as the rate of ROSC at 100 compressions
per minute.
• The other very important bit of data is that when the compression
rate exceeds 120 the rate of ROSC declines. You must maintain a
rate of 100.
• USE A METRONOME!!!!
121. The CIRC Trial
The results of an international study
utilising the autopulse and comparing
results to manual AHA standard cpr
with over 4,000 patients . The survival
was directly related to the compression
fraction.
122. Recoil
You must get your hands off
the chest as you do
compressions.
Where is the data?
123. • For good cardiac blood flow, recoil is key.
• When you compress the chest you are forcing
blood out of the heart and essentially
mimicking systole. The blood flow goes to the
brain and other organs
• When you recoil, your hands come off the
chest . You are mimicking diastole and
allowing the blood to flow to the coronary
arteries.
• DOWN-BRAIN….UP -HEART…
124. Should Intubation Be a Part of
Cardiac Resuscitation?
• There were three papers that examined this question from Los
Angeles, Michigan, & N.C. in 2010 with over 3600 patients with out
of hospital cardiac arrests. They all suggested that pre-hospital
patients who had no attempt at intubation were two to five times
more likely to survive.
• In a recent review of over 600,000 cardiac arrests in Japan the
patients who had BVM had better outcomes than the patients who
had endotracheal intubation. The patients who were intubated had
better outcomes than the patients who were ventilated by
extraglottic airways. The data from the ROC trial was very similar.
• Recently the CARES database reviewed their data with intubation
and the results were similar.
• THERE IS NO DATA THAT INTUBATION IMPROVES SURVIVAL IN
PATIENTS WITH CARDIAC ARREST!
125. • There is a lot of data that hyperventilation is harmful in cardiac
arrests. There is a lot of data that any interruption in chest
compressions is harmful. If intubation will be done , it must not
interrupt chest compressions and ventilation cannot be
allowed to be too frequent [the AHA recommends 6-8 per
minute, the tidal volume should be 6 ml per Kg] .
126.
127. • The patient must be treated on scene. Remember every minute
results in a 7-10 % loss of life per minute.
• From the preceding slide , the first responder goes to the chest and
initiates chest compressions.
• The second responder will place an oral airway , attach the monitor
and then initiate an I/O . The first dose of epinephrine should be
administered within 3 -5 minutes of arrival.
128. Summary
• Keep the patient on scene
• Push hard 2 inches
• Push fast 100-120 /minute , use a metronome
• Don’t stop, except to defibrillate every 2 minutes
• Recoil…. down saves the brain
• up off the chest saves the heart
• Delay intubation….Use a capnometer and if the
patient is intubated keep the ETCO2 35-40, never
hyperventilate
• PRACTICE makes perfect
142. WHAT IS INCLUDED IN CARES?
• Demographics
• Etiology
• Medical Metrics
– Presenting rhythm
– Etiology
– Time factors
– Bystander CPR
– ROSC
– Outcome
144. CONTENTS
• CAD or other dispatch
data
• AED review
• ALS review
• Hospital outcome
• Resources-mycares.net
for language on
approaching hospitals
for research databases
146. DATABASE ANATOMY
• How are you going to
get notifications of CA?
• Who will be managing?
• Where will you keep
your data?
• Is it secure?
• Who will have access?
• How will you present
your data?
147. BIG QUESTIONS
• How will you use the
data?
• How will you deal with
inquiries for the data?
• What will be the access
for stakeholders?
• Consistency of data and
coding
• Sustainability