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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