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Putting It All Together: The Future of Out of Hospital Cardiac Arrest (OHCA) CareRobert Katzer MD MBAAssociate Professor, Emergency MedicineUniversity of California, IrvineMedical Director, City of Anaheim Fire and RescueAir Medic, San Bernardino County Sheriff

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Disclosure Statement

No financial conflicts with the presentation topic

or content covered today

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Historic Bedrocks of Cardiac Arrest Management

Compressions

Airway Management

Epinephrine and other Medications

Defibrillation


PUSH

TUBE

BOLUS

SHOCK

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Epinephrine in Cardiac Arrest

• Been using it in cardiac for, essentially, forever(since dog studies in the 60’s)

• How it works:• Stimulates alpha adrenergic receptors resulting in the

increased aortic diastolic pressure resulting in pressure and perfusion of coronary arteries in theory increasing the chance of return of spontaneous circulation(ROSC)

• At what expense to perfusion to other organs?..


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Results of Epinephrine in Cardiac Arrest

• Increased rate of ROSC: pretty consistent

• Increased or unchanged 3 month survival

• Unchanged or worse neurologic outcomes


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A Japanese Group States it Best

“Conclusions: Pre-hospital administration of adrenaline by emergency medical services improves the long term outcome in patients with out of hospital cardiac arrest, although the absolute increase of neurologically intact survival was minimal.”2


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Mechanical Compression Devices


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Mechanical Compressions

• Data has demonstrated compression fraction is important for survival in cases of ventricular fibrillation.

• Logically during phases of patient movement it is very difficulty to maintain a high compression fraction.

• Mechanical compression devices increase safety for ems personnel during cpr in a moving ambulance


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Mechanical Compressions

• Some evidence exists to suggest mechanical compression increases compression fraction.

• Evidence that they lead to superior patient centered outcomes however has not emerged.


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Mechanical Compressions Bottom Line

• More money is being spent on these

• Whether these will become a standard of care

Or

• Be piled in storage next to the Mast Trousers (and back boards?)

• Remains to be seen


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Defibrillation


Image:www.jems.com

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Defibrillation Total Joules Used

Early defibrillation unequivocally works to save lives in Vtach and Vfib arrest.

Early defibrillation is more successful to this end.

There is not convincing data that 360 joules results in better patient centered outcomes than 200 joules


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Defibrillation

• Success of double sequential defibrillation has been illustrated in many anecdotal stories, case studies

• There is not any robust research to support its utility. Studies Please!!


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Airway Management

• For decades, out of hospital cardiac arrest care involved

• Establishing a definitive airway endotracheal airway


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Supraglottic Airways


igel

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Supraglottic Airways Vs. Endotracheal Intubation

Results are mixed

-No significant difference between SGA and ETI.

-Slight advantage in three day survival with SGA in one study.


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Supraglottic Airways Vs. Endotracheal Intubation

• Assuming patient centered outcomes are not inferior in SGA utilitization:• Does use of SGA improve compression fraction compared to ETI?• Does use of SGA allow decreased training costs?• Does use of SGA allow providers with more limited scope than

paramedic manage airway during cardiac arrest?


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Kahoot!

Kahoot Survey!


https://create.kahoot.it/share/the-future-of-out-of-hospital-cardiac-arrest/14547a9e-cda6-49dc-902e-adb8b093ca57

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Is the Secret to Increasing Patient Centered Outcomes a Deliberate Approach to Team Based Management?

Pit Crew CPR

The Rialto Method


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Pit Crew CPR

• Like Dizziness, means different things to different people

• Core theory is to maximize performance in compressions and deliver early defibrillation when indicated

• Outside of this core concept, the delivery varies between organizations

Department Name | Month X, 201XImage:https://www.dailymail.co.uk/sport/formulaone/article-4401632/Formula-One-pit-stop-does-crew-work.html

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Common Concepts in Pit Crew CPR

• Defined roles

• Adequate workspace

• Rapid Assessment

• High-performance CPR


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Pit Crew Team Roles Example

• One member at the head (airway/time keeping)

• One member at one shoulder

• One member at the other shoulder

• One member at the waist (ALS member focusing on ALS aspects), pulse checks


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High Performance CPR

• Per 2015 AHA Guidelines:• Perform chest compressions at a rate of 100-120/min• Compress to a depth of at leas 2 inches(5 cm)• Allow full recoil after each compression• Minimize pauses in compressions


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Minimize movement

• Focus on performing the resuscitation where the patient is

• Patient movement and transportation will invariably decrease CPR performance


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Phased Arrival of Providers

• BLS arrival initially, with assigned Compressions and aed roles

• As ALS unit arrives later they perform defined roles ALS functions


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The Rialto Method

• Rialto, CA fire Department• Seven Components

• Continuous uninterrupted compressions utilizing an automated CPR device

• Apneic oxygenation

• Use of impedance threshold device

• Heads up CPR

• Delaying defibrillation in certain conditions

• Expanded use of wave form capneography

• Deprioritizing epinephrine


Image: https://www.jems.com/articles/print/volume-42/issue-1/features/the-perfusing-cadaver-model-and-head-up-cpr.html

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Sounds Great, Where’s the Evidence?


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Study From Salt Lake City Evaluated Survival and Neurologic Outcome Before and After Implementation of Pit Crew Approach

• Hopkins Et al. J American Heart Association 2016

• Included all cardiac arrests during the period 9/1/2008 to 12/31/2014. (Trauma, strangulation, drowning, DNR, and signs of irreversible death excluded)

• 9/1/2008-8/31/2011: Before intervention group

• 9/1/2011-12/31/2014: Intervention group


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Salt Lake City Pit Crew Approach Implemented 9/1/2011

• CPR Quality Improvement Initiatives

• Airway Management

• Simplified Medication Algorithm

• EMS Crew Team Training


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Salt Lake City CPR Quality Improvement Initiatives

• Real time monitor/defibrillator feedback of compressions

• Medical director reviewed all arrests and gave feedback

• Monitor/defibrillator able to filter rhythmn during compressions

• Selective pulse checks based on parameters, not time

• Worked patient on scene for 30 minutes minimum


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Salt Lake City Airway Management

• Passive oxygenation x 6-8 minutes on witnessed arrests

• Asynchronous ventilation x 6-8 minutes on unwitnessed arrests

• No interruptions of compressions during intubation or laryngeal tracheal tube placement

• Impedence threshold device was added part way through the study


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Salt Lake City Medication Algorithm

• Intraosseos line used as first line access

• Atropine not utilized

• 34 degree saline administered up to 1 liter.


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Salt Lake City EMS Crew Training

• Autonomous team member roles instead of the traditional Team leader giving orders• Airway• CPR• Monitoring and defibrillation• Medication/access• Documentation


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Salt Lake City Destination Modification

Patients were all routed to ST elevation myocardial infarction receiving centers


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Salt Lake City Study Results:

Pre-intervention (9/2008-9/2011)

Post-intervention (9/2011-12/2014)

P-value (ifapplicable)

Study Patients 330 407

Neurologically in tact

25 (8%) 65 (16%) Not reported

Survived to discharge/Survivedto admission

36/98 (37%) 71/141 (50%) 0.037

Favorableneurological outcome

25 (26%) 65 (46%) 0.0005


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What is The Secret Ingredient?

Department Name | Month X, 201X Image: www.amazon.com

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What is The Secret Ingredient?

Real time monitor/defibrillator feedback of compressionsMedical director reviewed all arrests and gave feedbackMonitor/defibrillator able to filter rhythmn during compressionsSelective pulse checks based on parameters, not timeWorked patient on scene for 30 minutes minimumPassive oxygenation x 6-8 minutes on witnessed arrestsAsynchronous ventilation x 6-8 minutes on unwitnessed arrestsNo interruptions of compressions during intubation or laryngeal tracheal tube placementImpedence threshold device was added partwayIntraosseos line used as first line accessAtropine not utilized34 degree saline administered up to 1 liter.Autonomous team member roles instead of the traditional Team leader giving ordersAirwayCPRMonitoring and defibrillationMedication/accessDocumentation


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Pit Crew Conclusions?

• Focusing on early defibrillation, minimizing time off chest, are probably a good idea

• Building a team concept that focuses on this is probably a good idea

??


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Informal Poll

• Not a review article!

• Not performed within the bounds of the scientific method

• Asked of the following groups:• Members of the California EMS Medical Director Advisory

Committee(EMDAC)

• Faculty, fellows, and residents of the UC Irvine Emergency Department


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Question #1 The Most Significant Change in Management of Cardiac Arrest Care between 2018 and 2028

• No epi or other drugs (several people mentioned that)

• Automated cpr, no more manual cpr

• Tailoring resuscitation to the individual and monitoring both the cardiac and cerebral systems.

• The widespread adoption of high performance-CPR

• We don’t intubate


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Question #1(CONTD) The Most Significant Change in Management of Cardiac Arrest Care between 2018 and 2028

• All paramedics use a CPR vest

• The use of field ECMO (several people mentioned that)

• iPhones can now detect people going into cardiac arrest or other dysrhythmias. Their iPhone signals a very loud alarm, which signals other nearby iPhones, kind of like an Amber alert. “We will call it a Megan alert, since I’m the one who thought of it. This is totally different from Megan’s law”.

• Defibrillators in every home


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Question #2 The Second Most Significant Change in Management of Cardiac Arrest Care Between 2018-2028

• Use of impedance threshold devices with compression/decompression CPR devices

• head-of-bed elevated CPR.

• No intubation (several people mentioned this)

• End tidal co2 to determine adequacy or compressions


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Question #2 (CONTD) The Second Most Significant Change in Management of Cardiac Arrest Care Between 2018-2028

• The elimination of epinephrine (Several people mentioned this)

• There are new easy to insert lines that give measures of quality of CPR which have shown improved survival because quality CPR is all that matters.

• Wearable ultrasound with AI that directs shocks/medications and communicates with Lucas to optimize compressions

• You can use your iPhone for defibrillation and it gives you feedback on chest compressions.


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Question #3 Beyond the Above, the Most Surprising Change in Management has Been

• Use of REBOA intra-arrest to increase coronary perfusion pressure.• Prehospital cardiac transplantation with an artificial heart for out of

hospital cardiac arrest• Point of care ultrasound used by EMS personnel to determine

whether the patient needs transport to ED for care or they can be called at the scene

• The ability to go beyond monitoring the cardiovascular and CNS; being able prevent reperfusion damage to these systems despite prolonged downtimes

• Prehospital intracardiac thrombolytics


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Question #3 (CONTD) Beyond the Above, the Most Surprising Change in Management has Been

• Those mechanical CPR devices of 2018 were not great for outcomes• Doctors run codes in ambulances via telemedicine• ECMO is pretty easily accessible and easy to implement so it is

frequently used in younger patients while waiting to rule out reversible causes.

• Disposable TEE that wirelessly communicates with defibrillator machine

• less epinephrine use overall


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References

1.Perkins GD, Deakin CD et al. A Randomized Trial of Epinephrine in Out-of-hospital Cardiac Arrest. NEJM. 2. Nakahara S, Tomio J, Takahashi H et al. (epinephrine) by emergency medical services for patients with out of hospital cardiac arrest in Japan: controlled propensity matched retrospective cohort study. BMJ 2013;3473. Dumas f, Bougouin w, et al. Is epinephrine during cardiac arrest associated with worse outcomes in resuscitated patients? JACC Vol 64 NO. 22, 2014. 2360-23674.Callaway c. Questionin the Use of Epinephrine to Treat Cardiac Arrest. JAMA. Vol 307,no 11, 2012. 5. Hagihara A, Hasegawa M. Prehospital Epinephrine Use and Survival Among Patients With Out-of-hospital Cardiac Arrest. JAMA Vol 307 no. 11 20121161-11686. Hung SC, Mou CY et al. Chest compresions fraction in ambulance while transporting patients with out-of-hospital cardiac arrest to the hospital in rural taiwan. Emerg Med J. 2017 Jun;34(6)398-4017. Gyory RA, Buchle SE,. The Efficacy of LUCAS in Prehospital Cardiac Arrest Scenarios: A Crossover Mannequin Study. West J Emerg Med. 2017 Apr;18(3):437-4458. Gates S, Quinn T,. Mechanical chest compression for out of hospital cardiac arrest: Systematic review and meta-analysis. Resuscitation. 2015 Sep;94:91-79. Perkins GD, Lall R. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet. 2015 Mar 14;385(9972):947-5510. Fox J, Fiechter R,. Mechanical versus manual chest compression CPR under ground ambulance transport conditions. Acute Card Care. 2013 Mar;15(1):1-611. Satterlee PA, Boland LL. Implementation of a mechanical chest compression device as standard equipment in a large metropolitan ambulance service. J Emerg Med. 2013 Oct;45(4):562-91212. Mseka d, Johansson J, Huzevka T et al. A pilot study of mechanical chest compressions with the lucas device in cardiopulmonary resuscitation. Resuscitation 82 (2011) 702-70613. Gonzalez L, Oyler B, et al. Out-of-hospital cardiac arrest outcomes with “pit crew” resuscitation and scripted initiation of mechanical CPR. American Journal of Emergency Medicine article in press.14. Hopkins C, Burk c, Moser S et al. Implementation of Pit Crew Approach and Cardiopulmonary Resuscitation Metrics for Out-Of-Hospital Cardiac Arrest Improves Patient Survival and NeurologicOutcome. Journal of Amerihrican heart association 201615. Pit Crew Cardiac Arrest Resuscitation https://www.verywellhealth.com/pit-crew-cardiac-arrest-resuscitation-129817416. Pit Crew Approach to CPR has higher Patient Survival Rates. https://www.jems.com/articles/print/volume-41/issue-8/departments-columns/street-science/pit-crew-approach-to-cpr-has-higher-patient-survival-rates.html17. Pit Crew CPR Approach nearly doubles ROSC rate for Kan. Department. https://www.ems1.com/ems-products/cpr-resuscitation/articles/3032930-Pit-crew-CPR-approach-nearly-doubles-ROSC-rate-for-Kan-department/18. Rialto Fire Case study. https://www.zoll.com/medical-markets/ems/rialto19. The EMS Pit Crew Chief. https://www.jems.com/articles/supplements/special-topics/ems-10-innovators-ems-2009/ems-pit-crew-chief.html20. Putting the pit crew approach into practice. Ems world. https://www.emsworld.com/article/10796231/putting-pit-crew-approach-practice21. Highlights of the 2015 American heart Association Guidelines Update for CPR and ECG. American heart association. 22. The Perfusing Cadaver Model and Head-Up CPR. JEMS. https://www.jems.com/articles/print/volume-42/issue-1/features/the-perfusing-cadaver-model-and-head-up-cpr.html


https://www.verywellhealth.com/pit-crew-cardiac-arrest-resuscitation-1298174

https://www.jems.com/articles/print/volume-41/issue-8/departments-columns/street-science/pit-crew-approach-to-cpr-has-higher-patient-survival-rates.html

https://www.ems1.com/ems-products/cpr-resuscitation/articles/3032930-Pit-crew-CPR-approach-nearly-doubles-ROSC-rate-for-Kan-department/

https://www.zoll.com/medical-markets/ems/rialto

https://www.jems.com/articles/supplements/special-topics/ems-10-innovators-ems-2009/ems-pit-crew-chief.html

https://www.emsworld.com/article/10796231/putting-pit-crew-approach-practice

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