EMS TODAY 2013Mark Whitbread – Consultant Paramedic – London Ambulance Service

Future of Cardiac Arrest Management for

Paramedics

620 sq miles8.2 million population2011/12 – 1,617.032 999 (911) calls

London Ambulance Service NHS Trust

Specialist Centres

2011/1295, 270 999 (911) calls for chest pain8,251 999 (911) calls for cardiac arrest

What outcomes can be achieved ?

What equipment will be used?

What could be done differently?

What is the resp rate?

<10 - are we ventilating; 1 breath every 6 seconds? >10 - are sats titrated to 94-98%?

Have we got a FULL set of obs? (BP, HR, Sats, BM, 12 lead ECG, ETCO2)?

What is the BP? If <90, have legs been raised and a 250ml bolus of fluid given?

What is the pulse rate? If <60 and symptomatic has atropine 0.5mg been given?

Have further fluid boluses been considered if hypovolaemia suspected?

---------TAKE ANOTHER SET OF OBS----------

Effective chest compressions are ongoing and

compressors changed regularly?

Is the defib in manual mode?

Have we got sufficient O2? Is it attached to BVM

and bag inflated?

Is the chest rise adequate?

If traumatic arrest; has HEMS been considered?

Have a 2nd crew been requested / dispatched?

Family supported?

Does everyone know each other’s names? (If not, introduce self and indicate for others to state name and skill level)

Are effective continuous compressions on going?

Is the ECG rhythm being assessed every 2 mins?

Is there an ETCO2 waveform present and printed? If value <10mmHg...why?

Is there bilateral air entry?

Have we checked for tension pneumothorax?

Have we got access yet? Is it definitely PATENT?

Has fluid been given if hypovolaemia suspected?

Have we checked for gastric distension?

Adrenaline given and amiodarone if required?

Has BM been checked? Other reversible causes?

Are we using an FR2? Has it been swapped for a Lifepak if recurrent VF/VT?

Has CCD been contacted if up to 18 shocks given (paramedics)

Adult Cardiac Arrest Checklist © (Latest edition: September 2012)

On arrival ►►►►►►

CHECK

After ALS initiated ►►►►►►

CHECK

Post ROSC ►►►►►►

CHECK

Completed by:

Call sign: CAD: Date:

Lead paramedic:

Please see overleaf for ‘leaving scene’ Checklist ►►►►

Yes

Yes

No

Do NOT give adrenalineIs the BP <90?

Yes

No

Is the pulse rate <100?

Is the radial pulse absent? No

Give adrenaline 0.1mg 1:10,000 (note small dose), up to 0.5mg total

Do NOT give adrenaline

Do NOT give adrenaline

Cardiac Arrests are predictablePre planning is essential

Out of hospital6/65 Multi‐organ failure15/65 Cardiovascular

44/65 Neurological In hospital

31/65 Multi‐organ failure16/65 Cardiovascular14/65 Neurological

Issues ?

It’s almost impossible to do RCT’s in patients in  cardiac arrest

It’s difficult to increase cardiac arrest survival 

Guidelines are Guidelines and sometimes we just need to apply common sense – JFDI

One change will not increase survival

UK Cardiac Arrest Survival (Utstein)DH Ambulance CQI’s 2011/12

London 31.7%

24.7%

24%

23.6%

22.6%

20.5%

20.4%

18.7%

18.3%

17.4%

15.1%

10.8%

40%

15%

40% of patients with OHCA are found with VT/VF only 22% achieve ROSCThis is a priority group for further efforts to improve ROSC

Circ Cardiovasc Qual Outcomes 2010;3:63-81

LAS Non Shockable rhythms

ROSC Survival

PEA 27.45% 3.31%

Asystole 18.23% 0.98%

So…

Learn from the real world

…Defib download and crew feedback should be the “Norm”…

Quality of ambulance resuscitation

No chest compressions 48% of time

Number of compressions av. 64/min

Depth of compressions av. 3.4cm

Wik et al. JAMA 2005; 293: 299-304

Delays are common!

Chest Compressions

Pending FDA 510(k) clearance

Arrhythmia Management

Ultrasound in PEARapid/Real time/no side effects/Accurate/Allows critical decision making

Cooling

Issues To increase cardiac arrest survival is difficult

It’s almost impossible to do RCT’s in patient’s in cardiac arrest

Guidelines are Guidelines!

Sometimes we just need to apply common sense “JFDI”

One change in management will not increase survival 

Issues To increase cardiac arrest survival is difficult

It’s almost impossible to do RCT’s in patient’s in cardiac arrest

Guidelines are Guidelines!

Sometimes we just need to apply common sense “JFDI”

One change in management will not increase survival 

Arrest ROSC

2. How early to start cooling?

3. How deep to cool?

1. Best cooling method?

4. How long to keep cool?

tem

pera

ture

time

2

3

1

4

Controversial Issues of Cooling

Appropriate managementAppropriate destination

ROSC sustained to HAC & Survival

CRM/ChecklistRecognise this is seriousClose the loop in communicationEstablish leaderUse resources appropriatelyStep back & do global assessment

Education/Simulation/Training• Run simulation• See mistakes made• Correct mistakes• Prevent reoccurrence• Find a solution

THANK YOU

mark.whitbread@lond-amb.nhs.uk