what did american ever do for resucitation? · what did american ever do for resucitation? sol may...
TRANSCRIPT
What Did American Ever Do for Resucitation?
SOL May 5, 2017
Adelaide, South Australia
American Exit - 1776
Freedom to Innovate in Resuscitation
First Defibrillation of a Human - 1947
Inventing Modern CPR
Emergency Medical Technicians
Anesthesia Analgesia 1972; 51: 27-34
Intensive Care
Layperson CPR
• Lay people encouraged to learn mouth-to-mouth since 1966
• CPR was a “medical procedure” – MD, RN only • Recommendation to teach both ventilations
and chest compressions to lay people in 1974 [JAMA 1974; Suppl 18: 841].
Telephone CPR - 1985
Am. J. Public Health 75 (1985) 47e50.
Public Access Defibrillation – Casinos - 2000
NEJM 2002; 347: 1242-1246
Public Access Defibrillation – Airports - 2002
Public Access Defibrillation - 2004
• Train > 20,000 Laypersons
• Increased number who survived after OHCA
In-Hospital Cardiac Arrest
http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelines-Resuscitation
• Respiratory distress turns into CPR 20% of the time
• Preventing arrests in non-monitored beds (or non-ICU beds) improves survival
• Frequent reviews and debriefings improves outcomes for a hospital
Hands Only CPR - 2000
Systems of Care JAMA 2001; 285: 1164-1171
Trauma Centers vs. CA Centers Trauma Centers
• Reduce mortality in most injured patients
• Benefit is greatest in centers that treat the most patients
• Increased efficiency and process of care
Cardiac Arrest Center • ?
• ?
• ?
JAMA 2008; 299:1158-65
Implementation of Cardiac Arrest Systems
Dallas
Portland
Alabama
Seattle-KingCo
San Diego
Toronto
Pittsburgh
Vancouver
Milwaukee Data Coordinating Center, Seattle
Ottawa
ROC Sites 36,000 EMS personnel 260 EMS & fire services 24 million people 287 hospitals
Resuscitation Outcomes Consortium (ROC)
2005 2006
2007 2008
2009 2010
2011 2012
2013 2014
2015 2016
Commissioned in 2004
“To conduct clinical trials in cardiac arrest and life-threatening injury”
2005 2006
2007 2008
2009 2010
2011 2012
2013 2014
2015 2016
HS Shock
HS TBI
Rescue Shock
Rescue TBI
Hypo Resus
PROPPR
TXA
N=895; Annals Surg 2011; 253: 431-41
N=1,331; JAMA 2010; 304: 1455-64
N=192, J Trauma Acute Care Surg 2015; 78: 687-95
N=50; submitted
N=50; submitted
N=680; JAMA 2015; 313: 471-82
Ongoing
2005 2006
2007 2008
2009 2010
2011 2012
2013 2014
2015 2016
HS Shock
HS TBI
CPR Feedback
PRIMED
Rescue Shock
Rescue TBI
Hypo Resus
CCC
ALPS
PROPPR
TXA
PART
N=13,126, NEJM 2011; 365: 798-806
N=1,586; BMJ 2011; 342
N=895; Annals Surg 2011; 253: 431-41
N=1,331; JAMA 2010; 304: 1455-64
N=192, J Trauma Acute Care Surg 2015; 78: 687-95
N=50; submitted
N=50; submitted
N=23,711; NEJM 2015; 373: 2203-14
N=680; JAMA 2015; 313: 471-82
N=3,026; NEJM 2016; 374: 1711-22
NEJM 2011; 365: 787-97
Ongoing
Ongoing
2005 2006
2007 2008
2009 2010
2011 2012
2013 2014
2015 2016
HS Shock
HS TBI
CPR Feedback
PRIMED
Rescue Shock
Rescue TBI
Hypo Resus
CCC
ALPS
PROPPR
TXA
PART
N=13,126, NEJM 2011; 365: 798-806
N=1,586; BMJ 2011; 342
N=895; Annals Surg 2011; 253: 431-41
N=1,331; JAMA 2010; 304: 1455-64
N=192, J Trauma Acute Care Surg 2015; 78: 687-95
N=50; submitted
N=50; submitted
N=23,711; NEJM 2015; 373: 2203-14
N=680; JAMA 2015; 313: 471-82
N=3,026; NEJM 2016; 374: 1711-22
NEJM 2011; 365: 787-97
Ongoing
Ongoing
10 RCT completed over 11 years >44, 647 Subjects enrolled
(2 RCT still to be published)
As long as you start CPR immediately, delivering first shock within first 3 minutes results in similar outcome (N= 13,126)
Adding an Impedance Threshold Device to standard CPR does not change outcomes (N= 8,718)
Real-Time Feedback improves CPR performance, but we cannot detect changes in outcomes (N= 1,586)
In VF that was not terminated with the first shock, administering Amiodarone, Lidocaine or Placebo does not change outcome (N=3,026). Amiodarone and Lidocaine numerically a bit better (< % difference).
Continuous Chest Compressions are not better than 30 Compressions: 2 Breaths (N= 23, 711)
Reasons for Deaths
• Most common (70%) cause of death in ROC cohorts
• ~60% with withdrawal of life support (WLST)
• Median: 2 days
0
10
20
30
40
50
60
70
Perc
ent o
f Cas
es • Understanding
“Proximate Cause of Death” is essential.
• Should have also measured prognostic workup, testing, advanced directives.
Callaway et al. Resuscitation 2014; 85: 657-63
Final Outcome
Randomize
Intervention Random Effects 30 Variables
150 Variables
Circulation 2005; 111: 428-434
JAMA 2005; 293: 305-10 • Monitoring of real CPR in real field conditions
• Learned about disconnect between training and real practice
• Identified major source of variation in outcomes
• Accelerometer can measure chest compressions
• ETCO2 measures ventilation
• Impedance is backup
• CPR Feedback – Philips MRX talks / beeps to
remind compliance with CPR guidelines
Measure Q-CPR
CPR Process Measurements
Compression Rate CPR Fraction = % of time compressions being done Compression Depth Complete Release = Not leaning on patient during upstroke Ventilation
>45-50 mm
100-120 / min
Circulation 2013: 128:CIR.0b013e31829d8654
Measure CPR Quality
Pre-ROC Terminology
• Hands-off time • No flow time • Cardiac arrest of cardiac etiology • Major trauma • “Neurologically intact survival” (CPC)
ROC Terminology
• EMS-assessed Cardiac Arrest • EMS-treated Cardiac Arrest
• “Presumed Cardiac Cause” No Obvious Cause • CPR Process Measures • Chest Compression Fraction
• Functionally Favorable Survival (MRS)
Size and Shape
Not American
American
Diverse Population of United States
ROC (2005-7) Survival
02468
1012141618
Assessed Treated Japan
Compare ROC (2005-7) Survival
02468
1012141618
Assessed Treated
What is going on in Seattle?
Seattle’s Contributions
Tachydysrhythmia
Willingness to Act
Secret Sauce – Resuscitation Academy
• 1000 details – All are important – No single thing can improve outcome by itself – Variation ~ Systems
AED; Time to Call; Dispatch Delays; Wheel Stop to Patient time; BLS/ALS; Number of Providers on Scene; CPR Fraction; Airway; Ventilation Rate; Time to IV; IV/IO; Pre-shock Delay; Peri-shock Delay; Coronary Angiography; Cardiac Arrest Receiving Hospital; Withdrawal of Life Sustaining Treatment
Feedback during Research Trial
CPR Fraction during ROC Clinical Trial Participation (Pittsburgh)
Low-Dose / High-Frequency Training
• RQI – Now
Smartphone and Apps - 2007
Invented Things - CPR, ICU, EMT - Layperson CPR Measured Things - Quality of CPR - Why People Die - In-hospital Events Developed Education and Training - Guidelines, Smart Phones - Continuous Training - Hollywood Novel Ways to Improve Delivery - Telephone CPR - AED