marc conterato, md, facep office of the medical director nmas...
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Marc Conterato, MD, FACEP
Office of the Medical Director
NMAS and the HC EMS Council
Minnesota Resuscitation Consortium
DISCLOSURE STATEMENT
Medical Consultant:7-Sigma Corporation
CME Speaker for ZOLL
Circulation/Alsius Corp
Specializing in Resuscitative Hypothermia
and Emergency Medicine related issues
Advances in Resuscitation:
Pit Crew Approach
Uses a coordinated, preplanned, patient
centered approach
Emphasis on
An engineered process
Quality of chest compressions
Minimally interrupted chest compressions
Recognizing need to change compressors
Pit Crew Approach (BLS)
Advances in Resuscitation:
Pit Crew Approach
Initially designed for BLS systems
How does this change when ALS team
arrives?
Inserting the ALS team into the process
and obtaining a “division of labor”
Pit Crew Approach (BLS and ALS)
Advances in Resuscitation:
Refractory VF/VT
The patient in VF/VT receives standard
ACLS care per first responders and
EMS, including cardiac defibrillation,
epinephrine, sodium bicarbonate and
antidysrhythmics.
The resuscitation proceeds for thirty to
sixty minutes, and despite interventions,
the patient remains in refractory VF/VT.
CURRENT PRACTICE:
In the field What are the next options:
Continue resuscitation in the field (How long?)
Double defibrillation (How many times?)
Other medications (IV Beta-blockers, IV Calcium-Channel blockers, IV Intra-lipid therapy?)
Transport to the nearest ED with automated CPR in progress?
Then what?
Advances in Resuscitation:
Refractory VF/VT
Intervention with the use of Cardiac
bypass/ECMO/IAPB capability (Highly
specialized and needs specially trained
staff)
This is performed while automated CPR
is continued till perfusion is taken over.
Refractory VF/VT definition
Any patient that has VF/VT as
presenting rhythm, and then remains in
VF/VT after three countershocks
(AED/defibrillator) and requires
amiodarone, lidocaine or magnesium is
considered to have refractory VF/VT.
Advances in Resuscitation:
Refractory VF/VT
This is a “labor intensive” approach that requires coordination between Dispatch, EMS field providers, the receiving facility and the CCL.
The premise is that early access to the CCL with perfusion access (ECMO/IAPB) and on going CPR till either a coronary lesion is found and treated, or futility is identified, may allow survival in up to 40-50% of these patients.
Advances in Resuscitation:Pit Crew Approach and the Next Steps
BLS Pit Crew now expedites the next steps of care in the refractory VF/VT patient.
If ALS not yet on scene and AED in use, notifies incoming ALS team when second shock delivered
Prepares patient for rapid transfer to ALS vehicle when they arrive
Expedites airway and IV/IO placement
Becomes extra staff for ALS crew during transport to ECMO center
Original Research
Resuscitation Science
Minnesota Resuscitation Consortium's Advanced Perfusion and
Reperfusion Cardiac Life Support Strategy for Out‐of‐Hospital
Refractory Ventricular Fibrillation
(J Am Heart Assoc. 2016;5:e003732 doi:
10.1161/JAHA.116.003732)
Demetris Yannopoulos, MD*,1; Jason A. Bartos, MD, PhD1;
Cindy Martin, MD1; Ganesh Raveendran, MD, MPH1; Emil
Missov, MD, PhD1; Marc Conterato, MD4; R. J. Frascone, MD5;
Alexander Trembley, BS4; Kevin Sipprell, MD6; Ranjit John, MD,
PhD2; Stephen George, MD, PhD1; Kathleen Carlson, MD1;
Melissa E. Brunsvold, MD3; Santiago Garcia, MD7; Tom P.
Aufderheide, MD8
Initiative Results
Over the first 3 months of the protocol, 27 patients were transported with ongoing mechanical CPR. Of these, 18 patients met the inclusion and exclusion criteria. ECMO was placed in 83%. Seventy‐eight percent of patients had significant coronary artery disease with a high degree of complexity and 67% received PCI. Seventy‐eight percent of patients survived to hospital admission and 55% (10 of 18) survived to hospital discharge, with 50% (9 of 18) achieving good neurological function (cerebral performance categories 1 and 2). No significant ECMO‐related complications were encountered.
Conclusions : The MRC refractory VF/VT protocol is feasible and led to a high functionally favorable survival rate with few complications.
Current Initiative Results
as of August 2016 48 patients have been enrolled so far, but not all
have met criteria.
33 patients met criteria and 17 have survived to discharge with CPC scores of 1 or 2.
8 patients with PEA, with 3 survivors.
One patient currently status post protocol and expected to recover and be discharged.
52% survival rate so far.
Approximately 80% have had true CV causes for their refractory dysrhythmias (CA occlusions, CA dissections, etc).
Average on scene time for ALS team is @ 12 minutes
Advances in Resuscitation:
Pre-Arrival instructions
Before BLS and ALS can be activated,
PAI sets the stage for increasing
chances of ROSC
Patient care starts here…
Key elements for success
Formal/systematic screening for cardiac
arrest
Confident and assertive instruction for
providing Compression-only CPR (COCPR)
Performance measure to ensure quality
though call recording review
Measurement of quality metrics for all
stakeholders with appropriate feedback
Metrics
From: AHA Scientific Statement – Circulation . 2012; 125 648-655
Reduction of Bystander Time-to-Chest
Compressions Using a Dispatcher-Guided
CPR Algorithm
OBJECTIVE:
The earlier bystander compression-only CPR is
initiated has a significant effect on outcome of
out of hospital cardiac arrest (OHCA).
Dispatcher-assisted CPR is known to increase
rates of bystander CPR. This study evaluates
the effect of a novel dispatch guided bystander
CPR algorithm on the time between 911 call
receipt and initiation of bystander compression-
only CPR.
Reduction of Bystander Time-to-Chest
Compressions Using a Dispatcher-Guided
CPR Algorithm
METHODS: We conducted a retrospective review of all
cardiac arrests that received prearrivalinstructions from dispatchers in our secondary public safety answering point following implementation of our algorithm. Each case was analyzed for time between call receipt and initiation of chest compressions by bystanders. Outcome data was extracted from our CARES registry. The primary outcome was the time between call receipt and initiation of bystander chest compressions, and the secondary outcome was patient survival.
Reduction of Bystander Time-to-Chest
Compressions Using a Dispatcher-Guided
CPR Algorithm RESULTS:
A total of 85 cardiac arrests were identified in our review from 5/1/2014 to 5/1/2016. Our algorithm underwent serial revision during the study period, and each version of the algorithm covered the following number of cases V1.0-14, V1.1-22, V1.2-30, V1.3-5, V1.4-7 and V1.5-7. The average patient age was 58.6 years, and 65.9% were male. There were not any significant differences in patient age or gender between the cohorts
Seconds from call receipt to bystander compression occurred as follows: Algorithm V1.0-137; V1.1-181; V1.2-173; V1.3-177; V1.4-203; and V1.5-151. Our algorithm shortened the time to bystander compressions by 59 seconds compared to our pre-algorithm baseline of 210 seconds.
Our pre-algorithm rate of ROSC was 0.7% and 31.8% for pre and post EMS arrival. At the end of our study period, our ROSC rates were 1.2% and 27.8% pre and post-EMS arrival. Survival from cardiac arrest before algorithm implementation was 8.0% (n= 31) compared to a survival of 8.9% (n=55) at the end of our study period.
Barriers
Dispatcher uncertainty
Emotional distress
Lack of confidence
Tell them to do it vs
asking
Fear of harming
Fear of exposure
Reassure that it’s
compression only
What if it’s not a Cardiac Arrest
Non-Cardiac Arrest Moriwaki j. Emerg Trauma
Shock 2012; 5 Population based observational
study
910 received bystander CPR
26 (2.9%) did not suffer cardiac arrest
3 of 26 (11.5%) had complications of CPR
○ Tracheal bleeding
○ Minor gastric mucosal tear
○ Chest wall pain(minor Rib Fx vs muscle damage)
No case required special treatment
Seizure mimic
Proportion of OHCA among calls for seizure
Dami et.al. Emerg Med J 2011
2 year prospective observational study
> 18yo chief complaint seizure
12/561 (2.1%) were subsequently classified as CA by paramedics
Code as Seizure only if certain
Advances in Resuscitation:
AEDS and EMS
In order to increase ROSC rates,
bystander CPR and public AED use
must increase.
While bystander CPR rates have
increased across the country, AED use
rates are still low
Fear of use
Fear of “harming” by shocking an awake
patient
Advances in Resuscitation:
AEDS and EMS
How to overcome these problems:
Frequent training
Public education
First Responder “buy-in”
Providing “feedback” to First Responders
Advances in Resuscitation:
AEDS and EMS
North Memorial Ambulance AED Report
If you have used an AED prior to
the arrival of North Ambulance,
please fill out the NMAS AED
form via the QR code or website
http://bit.ly/1E2g6K2
Quality Dept: (763) 581-9968
EMS Run Number
_______________________
Advances in Resuscitation:
The Next Step
Cardiac arrest kills
approximately 300,000
per year in the US
Survival is variable from
~5% to 20%
Approaches 50% for
witnessed V-fib
Depends on many variables
Resuscitation involves a
complex “chain” of events
Success depends on all
Advances in Resuscitation:
The Next Step
In order to increase survival, we must be
willing to try “new things”, and possibly
make mistakes.
The earlier we activate the process of
resuscitation, the higher chance we
have of success.
EMDs, First Responders and the Lay
Public have to be our allies in this
process.
Special Thanks to:
Alex Trembley, NREMT-P
Field Training Officer, Quality Management
Specialist