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October 7, 2010

October 7, 2010. ~0700 hrs Sunset and Orleans Bellingham, Washington. 42 year old male. Riding bike to work, rush hour major street Noted to fall from bike without obvious cause Citizen CPR immediately started by 3 bystanders. 42 year old male.

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October 7, 2010

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  1. October 7, 2010 ~0700 hrs Sunset and Orleans Bellingham, Washington

  2. 42 year old male • Riding bike to work, rush hour major street • Noted to fall from bike without obvious cause • Citizen CPR immediately started by 3 bystanders

  3. 42 year old male • EMS arrival with CPR ongoing defib x 7, airway and rapid ED transport (too close to start field cooling) • Arrival in ED with vs, pt refibrillated and defib x 3. Cooling initiated on arrival • To cath lab with vs

  4. 42 year old male • In cath lab again fibrillated x 3 with defib • Cath => normal coronaries and acute cardiomyopathy • Cooled x 24 hrs, warmed and awoke day 3 • AICD placed and medical management • CPC/MRS <1

  5. April 24, 2011

  6. It all came together: - Citizen CPR- Dispatch assistance- Quick and aggressive EMS response- Coordinated ED response with defib and cooling (continued in cath lab)- Rapid cath lab transfer and skilled interventional cardiology- Critical care team and teamworkYou can makes a difference!!!

  7. More advances: • 4/10/11 • 63 yr old f “upset stomach” all day • Now chest pain • First EMS responders noted “sick” • Seizure like activity, CA, CPR, AED x 2 • ALS and EMS supervisor now on scene

  8. 63 yr old female • Pt woke with CPR went into PEA without, iced saline started • LUCAS® device applied, sedated to Intubate • Awake with CPR (LUCAS) “dead” without • To ED with device, brief pulse -> EKG • To Cath Lab with LUCAS on • Pulses returned in Cath Lab

  9. 63 yr old female • Cath -> Total LAD occlusion • Pulse, BP, slowly awoke post Cath

  10. "Saving Heart and Preserving the Brain...A New Paradigm for Resuscitation" Can we improve outcome from cardiac arrest?

  11. Marvin A. Wayne, MD, FACEP,FAAEMAssociate Clinical Professor University of WashingtonMedical Director Whatcom Medic OneEmergency Department St. Joseph HospitalBellingham, Washington USA

  12. Marvin A. Wayne, MD Disclosure

  13. Extent of the Problem Each year: • United States: 300,000 out-of-hospital cardiac arrests • Whatcom County area: ~270-300 out-of-hospital

  14. Cardiac Arrest • Treatment of cardiac arrest: • Unsatisfactory-In spite of new guidelines • Outcome from cardiac arrest: • Better but could be much better • Survival rate in Whatcom County (before 2005) • ~16% transported to hospital (95% VF) • <10% discharged from the hospital, unknown MRS • Long term survival in large cities = 3-5% • Previously no intervention has been shown to improve long-term survival with good neurologic function

  15. Cardiac ArrestWhat do we know? Current CPR’s effectiveness is poor… Forward blood flow during CPR is less than 25% of normal.

  16. So what can we do to make a difference?

  17. Change the dynamics of CPR • New CPR – Push hard push fast • Devices to assist • Manual • Mechanical • Improve blood return to heart • ITD • Decompression CPR

  18. Cardiac Arrest Research Human studies-concept: • Use of an Impedance Threshold Device (ITD) improves blood pressure during S-CPR • Use of an ITDwith S-CPR improves short-term survival

  19. ResQ POD™ • Prevents passive air entry during decompression cycle (diastolic) of CPR, • Prolonging negative ITP • Augments cardiac filling and CO • Timing light Impedance Threshold Device (ITD)

  20. Background: Impedance Threshold Device • Selectively prevents unnecessary air from entering the chest during the decompression phase of CPR

  21. ITD in Respiratory Circuit Facemask Basic life support Endotracheal Advanced life support

  22. Cardiac Arrest Research Human studiesconcept: ACD-CPR: • Active Compression Decompression-CPR(ACD) improves survival • So can combining an ITD with ACD-CPR result in improved long term survival?

  23. ResQPump® • Performs active compression decompression CPR (ACD-CPR) • Same as standard CPR (S-CPR): • Actively compresses the chest • Different from standard CPR (S-CPR): • Actively decompresses the chest, assists in augmenting negative intrathoracic pressure, diastolic filling

  24. Res Q Trial:Seven US Sites, NIH-NHLBI Funded Evaluate outcome in victims of cardiac arrest treated with: S-CPR vs. ACD-CPR + ITD Results: to compare short and long-term outcome

  25. Study Protocol (2470 pts) Cardiac Arrest Randomize by week ACD-CPR + ITD (840 pts) S-CPR (813 pts) • Standard Treatment • Intubation • Defibrillation • IV & medications ~800 patients per group Outcome

  26. Methods: Study Design • Prospective, randomized, controlled trial • Seven US sites • 46 EMS agencies • 4950 EMS providers • 23 IRBs • Population base: 2.3 million • Patients assigned to receive S-CPR or ITD + ACD-CPR on a 1:1 basis. • Study period: February 2005 – July 2009

  27. Methods: Research Question Is there a difference in survival to hospital discharge with good neurologic function (modified Rankin Score ≤ 3) between patients receiving: Standard CPR (control) ITD + ACD-CPR (intervention)

  28. Study Subject Inclusion • Adult cardiac arrest patients • 18 years old or greater • Non-traumatic • Out-of-hospital • Treated by EMS personnel with CPR

  29. Study Endpoints • Return of pulse • Survival to one hour • Survival to hospital admission • Survival to 24 hours • Survival to hospital discharge • Survival to 30, 90 & 365 days • Neurologic recovery (MRS ≤ 3) at hospital discharge, 30 days, 90 days, 1 year • Quality of life at 1 year • Complication rates

  30. The Lancet Jan 25, 2011 Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomized trialAuthors:Tom P. Aufderheide, M.D., Ralph J. Frascone, M.D., Marvin A. Wayne, M.D., et al

  31. Results: Primary Endpoint * *53% improvement P = 0.019 OR 1.58 CI (1.07, 2.36) Survival to Hospital Discharge with MRS ≤ 3

  32. Conclusions • 53% increase in survival with good neurologic function between the device and control groups • 50% increase in overall survival was observed from 3 months up to one year in the device group • ITD+ ACD-CPR device combination significantly increased survival with good neurologic function up to 90 days, and overall survival up to one year. • No significant differences in any safety endpoints or adverse events between the groups

  33. Results: Survival to 90-days and 1 year

  34. O RIGINAL ARTICLE September 1, 2011 A Trial of an Impedance Threshold Device in Out - of - Hospital Cardiac Arrest Tom P. Aufderheide, M.D., Graham Nichol, M.D., Thomas D. Rea, M.D., et al for the Resuscitation Outcomes Consortium (ROC) Investigators But now comes the ROC Primed Trial The NEW ENGLAND JOURNAL of MEDICINE

  35. Methods: ROC PRIMED Study Design • Prospective, randomized, blinded, controlled clinical trial with data analyzed on intent to treat basis • 10 sites in US and Canada • Study period: June 2007 – November 2009 • 2 x 2 multivariate study design • Analyze Early (30 secs CPR) vs Analyze Later (3 min CPR) • Sham vs Active ITD (both had timing lights) • Primary endpoint: survival to hospital discharge with Modified Rankin Score (MRS) ≤ 3

  36. Results:ROC PRIMED Primary Endpoint * Survival to Hospital Discharge with Favorable Neurologic Outcome *P = 0.71 CI (-1.1, 0.8)

  37. New Post Hoc Findings from ROC PRIMED The Relationship of Chest Compression Rate and Survival FromOut-of-Hospital CPR at ROC Regional Sites; Idris AH et al. Circulation 2012 Jun 19; 125:3004. • Findings: • Compression rates varied from 50 - 240/min • >1/3 of subjects had compression rates > 120/min • Compressions that were too slow or too fast associated with poor outcomes • Data include sham and active ITD outcomes

  38. Importance of Idris Results • Quality of CPR was highly variable in ROC study. • Rapid compression rates, similar to rapid ventilation rates, common and deadly. • While the compression rates were monitored, information was not used to improve CPR quality during the ROC study.

  39. Effect of Compression Rate on ITD -Efficacy from the ROC PRIMED Study Based upon findings by Idris et al, a post hoc analysis suggest rate of 100-120 best, more to come So what can we say today? A. Go to the AHA ReSSmeeting to hear about the new analysis… B. Like everything else in CA, quality of CPR is critical. Too many ventilations , too much epinephrine, too fast or slow compressions, results in worse outcomes. The ITD works well and is quite effective when CPR is performed per AHA Guidelines. Stay tuned!

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