Transcript Pre-hospital Resuscitation

Pre-hospital
Resuscitation
What’s new after “Guidelines 2005”?
K.S. Chew
School of Medical Sciences,
Universiti Sains Malaysia
Introduction
Chain of Survival
Early Recognition
and Activation of
EMS
Early CPR
Early
Defibrillation
Early ALS
(Cummins et al. 1991)
What This Talk IS NOT
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IS NOT a cut and paste lecture from
AHA/ILCOR Guidelines 2005
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IS NOT a description about the Malaysian
prehospital scenario per se
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IS NOT a critical appraisal on scientific articles
Another piece of evidence?
But…does it fit??
Four Main Key Points
Key Point No. 1
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We have good news – we are now back to a
single emergency number 999
But will the implementation be translated to an
improved, effective prehospital communication?
Prank calls
Multilingual?
Key Point No. 2
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Chest compression only CPR (without mouth to
mouth ventilation) is set to become more
important in the out of hospital setting
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That is a good news to us, especially in our
cultural setting
Key Point No. 3
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Energy levels in biphasic waveform defibrillator
is becoming more definite in the very near
future – it seems that higher energy (200J- 300J 360J) is associated with better outcome if more
than one shock required
Monophasic waveform is phasing out
Key Point No. 4
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New evidence has shown that for certain cases
of cardiac arrest patients who collapsed in the
out of hospital setting, paramedics can
terminate the resuscitation effort (even at BLS
level only) because the survival rate is very very
low.

Can this rule be applied in Malaysia?
Early Recognition
Early
Recognition
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About threequarters of out-ofhospital cardiac
arrests occur at
home or private
residences rather
than in public places
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Iwami et al., (2006)
Resuscitation 69, 221228
Are We Targeting Enough?
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Bystander-initiated CPR most frequently
takes place in public places such as the
street (Herlitz et al., 1994)
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How about the majority (up to 75%) of the
cases of cardiac arrest that occur at
home?
Early Activation of
EMS
www.999.gov.my
991 – Civil Defense Dept; 994 – Fire and Rescue
By January 2008, all calls to 991 and 994 will be re-routed
back to the 999 emergency call center
Prank Calls
In 2006, 98.9% of all
emergency calls received
turned out to be prank
calls
Section 233, Communications
and Multimedia Act 1998 - the
penalty for misuse RM50 000
fine, and/or one year's jail
The STAR, 25th October 2007
Early CPR
AHA/ILCOR Guidelines 2005
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Guidelines 2000
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Guidelines 2005
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15:2 for adults
5:1 for child
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One universal ratio 30:2
for ALL except neonates
Simplify CPR for
learning
Longer series of
uninterrupted chest
compressions.
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Chest Compression Only CPR
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Guidelines 2005:
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“….. encouraged to do compression-only CPR
if they are unable or unwilling to provide
rescue breaths (Class IIa), although the best
method of CPR is compressions ….. with
ventilations.”
Mouth To Mouth Breathing

The kiss of life or the barrier to CPR?
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Bystander CPR only performed in less than
1/3rd of out of hospital cardiac arrests
Complicated technique
Fear of transmission disease
Cultural barrier in Malaysia
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SOS-KANTO Study
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Prospective, multicenter, observational
In Kanto region of Japan
Witnessed, out of hospital cardiac arrest
Primary endpoint - favourable neurological
outcomes at 30 days after cardiac arrest
Secondary endpoint – survival 30 days after
cardiac arrest
Cardiopulmonary
resuscitation by bystanders
with chest compression only
(SOS-KANTO): an
observational study. Lancet
2007; 369 (9565):920-6.
72%
18%
11%
Lancet 2007; 369 (9565):920-6
Key Findings of SOS-KANTO Study
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Out of the 4068 adults who had out-of-hospital
cardiac arrests:
72% did not receive CPR from a bystander
 18% received full CPR from a bystander, and
 11% received chest compression alone from a
bystander
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Any resuscitation is better than no resuscitation
at all (in terms of favourable neurological
outcome at 30 days) [5% vs 2%, p<0.0001]
Key Findings of SOS-KANTO Study
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Chest compression only is better than chest
compression PLUS mouth to mouth in these THREE
subgroups of patients:
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Those with apnea [6% vs 3% (p=0.0195)]
Those with a shockable rhythm [19% vs 11% (p=0.041)]
Those who received CPR within 4 minutes [10% vs 5%
(p=0.0221)]
NO subgroup showed any benefit from the addition of
mouth to mouth breathing
Why Chest Compression Alone is
Preferred for Bystander CPR?
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Advantages to the rescuer
Simplify technique
More willing to perform
Advantages to the patients
Less interruptions of essential chest compression
Mouth-to-mouth may actually increase intrathoracic
pressure and reduce venous return
Ventilation maybe unnecessary especially during initial
stage when the oxygen tension is still adequate
Prompt Guidelines Revision?
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“This finding (SOS-KANTO’s) is an important
piece of evidence that should lead to a prompt
interim revision of the guidelines for out-ofhospital cardiac arrest. Eliminating the need
for mouth-to-mouth ventilation will
dramatically increase the occurrence of
bystander-initiated resuscitation efforts and
will increase survival.”
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(Ewy 2007, in an editorial comment in Lancet)
A Blanket Rule Doesn’t Apply
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“We should, for now, to follow the newer
guidelines [guidelines 2005] of assisted
ventilations and chest compression [meaning
ratio 30:2] for respiratory arrest (such as in
drowning and drug overdose), but the guidelines
should promptly be changed to chestcompression alone for witnessed unexpected
sudden collapse…”
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(Ewy 2007, in an editorial comment in Lancet)
Ultimately our aim
is to get more
public member to
perform bystander
CPR!!!
Not just knowing.. but willing
The Challenges within the Malaysian
Context
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SOS-KANTO’s findings - a good news to us
Encourage more public, not just to know, but
also to be ready and willing to perform
bystander CPR
IF steps simplified (chest compression only) –
knowledge can also be disseminated to more
public members – e.g. through short
documentary clips in TV, etc
Early Defibrillation
AHA/ILCOR Guidelines 2005
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“The optimal energy for first-shock biphasic
waveform defibrillation … has not been determined”
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“Multiple .. studies have failed to identify an optimal
biphasic energy level for first or subsequent shocks.
Therefore, it is not possible to make a definitive
recommendations for the selected energy for first or
subsequent biphasic defibrillation attempts.”
Introduction: BIPHASIC Trial
(Stiell et al. 2007)
BIPHASIC Trial
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Triple blinded (blinded to researcher, patient and
healthcare provider)
Randomized, Multicenter, Manufacturer-funded
Compare fixed lower energy (150J-150J-150J) or
escalating higher energy level (200J-300J-360J)
Primary outcome – successful conversion to an
organized rhythm
Secondary outcome – termination of VF/pulseless VT
regardless of the post-shock rhythm
BIPHASIC Trial
BIPHASIC Trial
If only a single shock is required,
NO DIFFERENCE either using a
lower or higher energy level
When
multiple
shock
required,
BIPHASIC Trial
then higher energy escalating
level is better
Implications of BIPHASIC Trial
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AHA/ILCOR Guidelines 2005 clearly states
that three stacked shocks are no longer
recommended (as per Guidelines 2000)
Rather, the Guidelines 2005 recommend a high,
single shock followed immediately by resuming
chest compression
This is to minimize delay in chest compression
Implications of BIPHASIC Trial
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This study implies that if fixed lower energy
regimen is chosen, many patients probably were
still in VF while CPR is going on
Which means that there will be a need for
additional shocks; thus causing interruptions in
chest compression
This seems to go against the recommendation
of AHA/ILCOR Guidelines 2005 of a single
shock in minimizing interruption??
Back to square one?
Question we may need to answer in the future is
Should we start with
ONE, SINGLE,
HIGHEST energy level
for biphasic waveform?
And what is that level of energy?
Early ALS
Let’s Face the Reality!
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Generally, the survival rate after a out of hospital
cardiac arrest is extremely low - <5%!
There is no evidence that these rates are
increasing, despite extensive use of advanced
treatments and technology
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(Vaillancourt and Stiell, 2004)
Even in large cities in US, the overall survival
has been quoted as ~1%
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(Ewy 2006)
Which Patients Should Be
Transported Back?
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“..resuscitation attempts should be terminated
when the patient remains in asystole despite full
advanced life support procedures for more
than 20 minutes”
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Recognition of Life Extinct (ROLE) Guidelines by
the Joint Royal Colleges Ambulance Liason
Committee
Then how about those with only basic life
support measures given by the paramedics and
EMTs with the use of AEDs?
Termination of Resuscitation (TOR)
Study
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In NEJM 2006, Morrison et al reported their
prospective validation of their previously
published TOR clinical prediction rule
(developed in 2002) that was derived
retrospectively.
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Morrison LJ, Visentin LM, Kiss A et al. Validation
of a rule for termination of resuscitation in out-ofhospital cardiac arrest. N Engl J Med 2006; 355
(5):478-87.
TOR Prediction rule
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1.
2.
3.
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Termination of BLS resuscitation should be
considered when
There was no ROSC at all before transport
No shocks indicated/given before transport
It was not witnessed by the EMS personnel
The authors found that only 0.5% of patients
survived if all THREE criteria are present
TOR Prediction rule
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Out of the 1240 patients, 776 patients fulfilled
criteria to apply the TOR rule.
Out of this 776 patients, only 4 survived (0.5%)
Positive Predictive value 99.5%
Specificity 90.2%
Results
Disadvantages Of Transporting
Refractory Cardiac Arrests
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Limits availability of EMS personnel
Increasing patient’s waiting time
Decreases availability of bed
Emergency lights and siren by ambulance driver
– pose risks to motorists, pedestrian, etc
EMS personnel performing interventions in a
moving vehicle or engaged in resuscitation are at
increased occupational biohazards risk
Wasting Of Resources In Transporting
A so called “Futile” Cardiac Arrest
Case?
REALLY???
Guidelines remain Guidelines
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“In an editorial published more than 20 years
ago, Cummins and Eisenberg suggested that
prediction rules for the termination of
resuscitation efforts should remain advisory
and that they should be tempered by the clinical
picture, taking into account the very small
possibility of successful resuscitation when
the prediction rules suggest termination”
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(Morrison et al. 2006)
Can Our Paramedics
Be Reliably
Depended Upon To
Terminate
Resuscitation and
sending the patient
to mortuary?
… or even to start
resuscitation?
Can TOR guidelines be applied in
Malaysia?
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Yes and no
Issues yet to be resolved:
For how long BLS continued before we call it
off as no ROSC achieved?
Who are in the ambulance? Any doctor?
Legal right/authority of paramedics to declare
death
Conclusion
What Would The Future Be
In The Area Of
Pre-hospital
Resuscitation?
Within the Malaysian context?
Conclusion
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Many more studies on chest compression alone
bystander CPR expected to follow after SOSKANTO study
Chest compression alone CPR set to become
more important in the out of hospital setting;
more definite indications in the future
Conclusion
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Energy regimen for biphasic waveform
defibrillator?
Energy levels in biphasic waveform defibrillator
set to become more definite in the very near
future
Monophasic waveform is phasing out
More manufacturers will reconfigure the energy
level regiment in their AED product
Termination of resuscitation in the field? That I am
not so sure! Most probably still a long way ahead
A Tale of Our Very Own
References
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Cummins RO, Ornato JP, Thies WH et al.
Improving survival from sudden cardiac arrest:
the "chain of survival" concept. A statement for
health professionals from the Advanced Cardiac
Life Support Subcommittee and the Emergency
Cardiac Care Committee, American Heart
Association. Circulation 1991; 83 (5):1832-47.
Ewy GA. Cardiac arrest--guideline changes
urgently needed. Lancet 2007; 369 (9565):882-4.
References
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Stiell IG, Walker RG, Nesbitt LP et al.
BIPHASIC Trial: a randomized comparison of
fixed lower versus escalating higher energy levels
for defibrillation in out-of-hospital cardiac
arrest. Circulation 2007; 115 (12):1511-7.
2005 American Heart Association Guidelines
for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation
2005; 112 (24 Suppl):IV1-203.
References
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Ewy GA. Cardiac resuscitation--when is enough
enough? N Engl J Med 2006; 355 (5):510-2.
Morrison LJ, Visentin LM, Kiss A et al.
Validation of a rule for termination of
resuscitation in out-of-hospital cardiac arrest. N
Engl J Med 2006; 355 (5):478-87.
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