John Tobin was the keynote speaker at the EMS track for ASM 2014 and gives an account of where he works and the efforts they have made to pre-hospital deaths in his EMS. Find out more at singem.blogspot.sg

1. A Paradigm Shift
in Cardio-Pulmonary Resuscitation
John Tobin
Alarm Room Captain
Mesa Fire/Medical Department

2. www.CPR360.org

4. Mesa Fire/Medical Department
• Full Service Fire Based EMS Agency
• 20 Fire Stations
• 40+ Responding Units
• Special Teams – Maz Mat/TRT/Bike
• Fire and Life Safety Education
• Fire Prevention
• 450,000 Residents/132 square miles
• Third-Largest City in Arizona
• 38th-Largest City in the United States
Approximately
1 Cardiac
Arrest Per Day

5. Changing Your Organizations
Resuscitation Mind-Set

6. AHA Chain of Survival

7. Our Mindset
VF is a survivable rhythm
We must consistently provide high
quality CPR
This requires a number of disciplined
behaviors/actions

8. We use Synergy
•MICR
•High Quality CPR
•Real Time CPR
Feedback
•Pit Crew Method

9. Using these methods
Improved OHCA
survival to discharge
2.72 times

10. You Choose
• Pick the method of CPR that works for
you
• Pick the equipment that works for you

11. OHCA Survival in
Arizona
Arizona
2004
50
40
30
20
10
0
Bobrow et al, Prehospital Emergency Care 2008;12:381-387
%
3%
“With so few
survivors, we felt
compelled to make
modifications to
protocol based upon
current evidence
and track the
results closely.”

12. CArdiocerebral Resuscitation (CCR)
200 chest
compressions
200 chest
compressions
Single shock
without pulse
Check or rhythm
analysis
Passive Oxygen
Insufflation/15L 02
Begin IV/IO
Analysis
200 chest
compressions
Single shock if
Indicated without
pulse check or
rhythm analysis
Analysis
Single shock if
Indicated without
pulse check or
rhythm analysis
Resume Standard ACLS
Consider Endotracheal
Intubation
200 chest
compressions
CCC
Only•
EMS
arrival
Administer 1 mg
IO/IV Epinephrine
Analysis
• If adequate bystander chest compressions are provided, EMS
providers perform immediate rhythm analysis
EMD Instructions CAC

13. Results: Survival from Out of Hospital Cardiac
Arrest in Arizona
0
5
10
15
20
25
30
All cardiac arrests Witnessed with VF
SurvivaltoHospitalDischarge(%)
ALS
CCR
3.6
9.2
10.9
28.1
(61/1686)
(55/598)
(33/348)
(36/128)
January 2005 – November 2007
Bobrow , J. (2008)

14. Why We Think
Minimally Interrupted Cardiac Resuscitation (MICR)
Works
• Minimizes interruptions of marginal forward
blood flow during resuscitation efforts
• Minimizes hyperventilation during
resuscitation
• Delay in advanced airway interventions may
enable providers to focus on compressions

15. Standard CPR (with breaths) vs. CC alone
Berg et al, 2001
Bloodpressure
Time
= chest compression
Bloodpressure
Time
Standard CPR
MICR

16. Clinical Trial with Zoll Medical, University of
Arizona, & Arizona DHS
• Zoll E Series Monitors
• Defibrillator Pads
had The PUCK

17. Our ProjectPhase 1: Measurement of CPR
quality with CPR feedback
disabled (18 months)
Training: Scenario-based
training of 450
EMTs/paramedics with use of
CPR feedback during training
Phase 2: Measurement of CPR
quality with CPR features
enabled (16 months)

18. Survival Increased at a CA Hospital with
Similar Quality Improvement Process
Survival to discharge improved from 21% to 36% with
aspects of this protocol
• Depth=2.6 in
• CC Fraction= 91%
• Pre-shock pause= 2.6 s
• Post-shock pause= 3.6 s
Dan Davis et al.
UCSD

19. MFD MICR Averages
(before un-blinding)
• Rate of compressions
• 128/min
• Depth of compression
• 1.78”
• Time to 1st Epi
• 6 minutes
(from on-scene time)
• Pre-shock pause
• 27 sec.
• Post-shock pause
• 40 sec.
• CC Fraction
• 66%

21. What to Train
Meaney, P. (2013)

22. Five Main Components of
High-Performance CPR
1. Chest Compression Fraction
2. Chest Compression Rate
3. Chest Compression Depth
4. Chest Recoil
5. Ventilation
Meaney, P. (2013)

23. Maximize the CCF!
• Choreograph Team Activities – Pit Crew
• Don’t stop compressions during AAP
• Avoid Unnecessary Pulse Checks
• Minimize Perishock Pauses
• Continue Compressions During Charging
• Start Compressions After the Shock without Delay
Meaney, P. (2013)

24. Compression Interruptions
18% decrease in survival
to hospital discharge for
every 5-second increase
in preshock pause
Cheskes et al. Circulation. 2011;124:58-66.

25. CPR Feedback
“Given the insights into clinical
performance and discoveries in optimal
practice, monitoring of CPR quality is
arguably one of the most significant
advances in resuscitation practice in
the past 20 years and one that should
be incorporated into every
resuscitation and every professional
rescuer program.”
Meaney, P. (2013)

27. Example of resuscitation WITHOUT feedback- NO ROSC
Depth = 1.39 in.
Rate = 148 CC/min
CPR fraction = 51%

28. Example of resuscitation WITH feedback
Depth = 2.25 in.
Rate = 99.86 CC/min
CPR fraction = 93%

29. Factors Affecting High Quality
CPR
• Compressor Fatigue
• Advanced Airway Placement
• Transportation

30. Example of resuscitation No ROSC
FATIGUE

31. Critical Points for MICR
• No transport until completion of MICR
• The best chance our patient has is for us
to complete this protocol prior to
transport.

32. Arrive EDDepart sceneScene
CPR Quality Decreases During
Transport

33. The Pit Crew
Method

34. PIT CREW:
How it’s Done
• Every member has a role
• Coaching
• Four, two minute cycles
• Compressor changes
• every 2 minutes
• Delay in Advance Airway Placement
• IO is first line vascular access

35. 4 Person Pit Crew

36. Importance of qa
“Review of the quality and
performance of CPR by professional
rescuers after cardiac arrest has
been shown to be feasible and
improves outcomes.
Despite this evidence, few healthcare
organizations apply these
techniques to cardiac arrest by
consistently monitoring CPR qualityMeaney, P. (2013)

37. Our Results

38. OHCA - Survival to Hospital
Discharge
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
All Rhythms Witnessed -
Shockable
8.70%
26.30%
13.90%
55.60%
10/2008 to 3/2010
5/2010 to 9/2011
Bobrow et al, Annals of Emergency Medicine 2013
2.72 times
more likely
to survive

39. OHCA – Favorable
CPC 1 or 2
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
All Rhythms Witnessed -
Shockable
6.5%
19.6%
10.8%
45.7%
10/2008 to 3/2010
5/2010 to 9/2011
Bobrow et al, Annals of Emergency Medicine 2013

40. OHCA – Favorable
CPC 1 or 2
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
All Witnessed Rhythms Witnessed Vfib/P-Vtach
10.80%
45.70%
19.79%
41.66%
12.20%
24.34%
2011
2012
State
Arizona SHARE Data 2012

41. Take Aways
• High Quality CPR
• Minimize Pauses
• Rate
• Depth
• Ventilations
• Real Time CPR Feedback
• Pit Crew
• QA/Debriefing

42. Thanks for all
You do!!

43. Questions?

44. Contact Information:
John Tobin
Alarm Room Captain
Paramedic
www.mesaaz.gov
Mesa Fire/Medical Department
John.Tobin@mesaaz.gov

45. Recruit Training Video
http://youtu.be/Umrc9eiy4H4