CT EMS EXPO SCA SYSTEMS

PAVING THE WAY FOR A
STRONGER
RESUSCITATION SYSTEM
OF CARE

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.

PLEASE HOLD YOUR QUESTIONS
FOR THE Q&A PERIOD

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WHAT IS AN IDEAL
SYSTEM OF CARE?
KAMIN

What Is A “System of Care”

First, Where are We At Currently?

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

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

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

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

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 ISSUES IN RESUSCITATION
QUALITY
THAT FRACTURE
THE CHAIN OF
SURVIVAL
HILTZ

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

RESUSCITATION
SCIENCE REVIEW
GELLER

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.

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

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

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.

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

The initial phase of a cardiac
arrest is responsive to
defibrillation. The response is very
time sensitive

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

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

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

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!!!

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.

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.

The Key
• Push hard [to 2 inches]
• Push Fast [100 per minute]
• Recoil [get your hands off]
• And
• Don’t Stop [for 2 minutes]

Push Hard
•Where is the data

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

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.

• 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!].

• Where is the data ?
PUSH FAST

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

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.

Don’t Stop
Continuous Compressions
Where is the data?

During cardiac arrest, chest
compressions are the patient’s heart
beat
Therefore, one needs to assure near
continuous chest compressions!

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 %.

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.

Recoil
You must get your hands off
the chest as you do
compressions.
Where is the data?

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.

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.

Disadvantages of Ventilation During CPR:
• Delays/interrupts chest compressions
• Stops bystanders doing CPR?
• Gastric inflation – aspiration
• Increased intrathoracic pressure
• Reduces coronary/cerebral perfusion
• worse outcomes

• 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] .

WHO OWNS THE RESPONSIBILITY?
KAMIN

A PROBLEM WITHOUT AN OWNER
-FREE / OBO-
SUDDEN CARDIAC ARREST

LET’S TAKE A BALLOT!
SHOULD EMS “OWN” OOH SCA?
YES or NO

DISPATCHER
CPR!
HILTZ AND GELLER

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

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.

Six Seconds
• That means that EVERY 6 seconds will KILL 1%
more people ! Think about that when you ask
more questions.

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 .

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.

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.

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.

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”

“ 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…

• “The balance greatly favors beginning CPR whenever a
patient is determined to be unresponsive and not breathing
,OR NOT BREATHING NORMALLY.”

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!

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

Why not Mouth to Mouth Breathing in
Adult CPR ?

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!

Dispatcher Goals
• Be Fast!
• Be Aggressive!
• Be unafraid!

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

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.

Measurement of Critical Variables
• Witnessed?
• Time of collapse?
• Bystander CPR?
• Dispatcher CPR offered?
• Dispatch CPR performed?
• Time intervals?

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?

• 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

EMPOWERING
ORDINARY PEOPLE
TO DO
EXTRAORDINARY
THINGS
A PERSPECTIVE ON
HANDS-ONLY CPR
HILTZ

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.

HIGH DOSE LOW FREQUENCY
VS.
LOW DOSE HIGH FREQUENCY?

IMPROVING
ACCESS
TO AEDS
HILTZ

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.

http://www.channelonline.tv/channelonline_jerseynews/displayarticle.asp?id=510614

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

HIGH PERFORMANCE CPR
GELLER AND SPENCER

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!!!!

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.

• 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…

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!

• 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] .

• 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.

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

RESUSCITATION
QUALITY
IMPROVEMENT
SPENCER AND HILTZ

MEASURE AND IMPROVE…
CARDIAC ARREST REGISTRIES
KAMIN

WHY HAVE A REGISTRY?
You can’t manage, what
you don’t measure

WHAT IS INCLUDED IN CARES?
• Demographics
• Etiology
• Medical Metrics
– Presenting rhythm
– Etiology
– Time factors
– Bystander CPR
– ROSC
– Outcome

BUT WHAT IF I CAN’T JOIN CARES?

CONTENTS
• CAD or other dispatch
data
• AED review
• ALS review
• Hospital outcome
• Resources-mycares.net
for language on
approaching hospitals
for research databases

WE KNOW WHAT
YOU ARE
THINKING...
LET”S TALK ABOUT HIPAA

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?

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

CT EMS EXPO SCA SYSTEMS

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