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

nmasqa@northmemorialambulance.com

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