The Prehospital & The Prehospital & Transport Medicine Transport Medicine Research ProgramResearch Program

Sunnybrook & Women’s College Health Sciences Centre

Funding AgenciesFunding Agencies

Resuscitation Outcomes Resuscitation Outcomes ConsortiumConsortium

ROC SitesROC Sites

Toronto Regional Toronto Regional RESCUeNETRESCUeNET

TORONTO Regional RESuscitation TORONTO Regional RESuscitation RESearch RESearch oUt of hospital oUt of hospital NETworkNETwork

Toronto Regional Toronto Regional RESCUeNET SitesRESCUeNET Sites

DurhamDurham HamiltonHamilton MuskokaMuskoka Ontario Air Ontario Air

Ambulance Ambulance ProgramProgram

PeelPeel SimcoeSimcoe TorontoToronto YorkYork

The ROC Structure:The ROC Structure:The 30,000 Foot OverviewThe 30,000 Foot Overview

National Institute of Health(NIH)

Resusitation Outcomes Consortium

(ROC)

University of Washington(Data Coordinating Centre)

Canadian Institute of Health Research

(CIHR)

Departments of Defense(Canada & US)

10 Sites(2 Canada & 8 US)

Toronto RegionalRESCUeNET

· 8 EMS Services· 32 Fire Services· 28 Dispatch Centres· 5 Base Hospitals· 53 Receiving Hospitals

Registry ProtocolRegistry Protocol

RegistryRegistry Epidemiological Databank (Epidemiological Databank ( registry) of:registry) of:

– Out-of-Hospital Cardiac ArrestsOut-of-Hospital Cardiac Arrests– Major traumaMajor trauma

Population based (includes all cases)Population based (includes all cases)

In-hospital outcomesIn-hospital outcomes

Regional specific information to the Service / Base HospitalRegional specific information to the Service / Base Hospital– Web-based and password protectedWeb-based and password protected

Form the basis of a Canadian Registry of Out-of-Hospital Form the basis of a Canadian Registry of Out-of-Hospital ResuscitationResuscitation

CIHI – linkage with other data sets (trauma, cardiac care, stroke, CIHI – linkage with other data sets (trauma, cardiac care, stroke, oncology)oncology)

Proposed ProtocolsProposed Protocols

CardiacCardiac

CPR: Back to the BasicsCPR: Back to the Basics

Compelling EvidenceCompelling Evidence

NegativNegative e

ImpactImpact

NeutraNeutraIImpacIImpac

tt

PositivPositive e

ImpactImpact

More Compelling More Compelling EvidenceEvidence

CobbCobb – observational - 1999 (3 years-639 pts vs 2 years- – observational - 1999 (3 years-639 pts vs 2 years-478 pts)478 pts)– 90 seconds CPR prior to shock 90 seconds CPR prior to shock – survival to hosp discharge (30% vs 24%)survival to hosp discharge (30% vs 24%)

WikWik – randomized - 2003 (200 pts) – randomized - 2003 (200 pts)– 3 minutes of CPR3 minutes of CPR– survival to hosp discharge (22% vs 15%)survival to hosp discharge (22% vs 15%)

AbellaAbella – prospective observational study – 2005 (67 pts) – prospective observational study – 2005 (67 pts)– Ventilations rates of 20/min (61%) (AHA guidelines are 10 to Ventilations rates of 20/min (61%) (AHA guidelines are 10 to

12/min)12/min)

WikWik – prospective observational study – 2005 (176 pts) – prospective observational study – 2005 (176 pts)– Rate of compression 64/min (AHA guidelines are 100/min) Rate of compression 64/min (AHA guidelines are 100/min) – Depth of compression 34 mm (AHA guidelines are 38 to 52 mm) Depth of compression 34 mm (AHA guidelines are 38 to 52 mm) – Hands off time 48% (38% when exclude ECG & shock analysis)Hands off time 48% (38% when exclude ECG & shock analysis)

Three-Phases of VFThree-Phases of VF

0 2 4 6 8 10 12 14 16 18 20

Arrest Time (min)

Circulatory

Phase

Elec trical

Phase

Metabolic

Phase

Shock CPR ?

Analyze Later versus Analyze Later versus Analyze EarlyAnalyze Early

300 compressions

Apply AED& Turn On

Apply ITD30-60 sec

Compressor Other Provider(s)

Analyze/shock

ACLS

3 min

50 +compressions

Apply AED& Turn On

Apply ITD30-60 sec

Compressor Other Provider(s)

Analyze/shock

ACLS

Impedance Threshold Impedance Threshold ValveValve

ResQPODResQPOD

WHO? WHO?

Inclusion Criteria:Inclusion Criteria: Age Age >>18yrs18yrs

Non-traumatic cardiac arrestNon-traumatic cardiac arrest

Receive defibrillation &/or CPR by EMSReceive defibrillation &/or CPR by EMS

Monitoring the Quality of Monitoring the Quality of CPRCPR

TraumaTrauma

Hypertonic Saline and Hypertonic Saline and DextranDextran

AdvantagesAdvantages

250 ml ~ 3 litres of Ringer’s 250 ml ~ 3 litres of Ringer’s lactatelactate

↓↓ early systemic inflammatory early systemic inflammatory responseresponse

↓↓ incidence of sepsisincidence of sepsis

GoalGoal

↑↑SurvivalSurvival

↑ ↑ Cognitive PerformanceCognitive Performance

↓↓ Multi Organ Dysfunction Multi Organ Dysfunction (MOD)(MOD)

Who?Who?

Hypovolemic Cohort Inclusion Criteria:Hypovolemic Cohort Inclusion Criteria: Blunt or Penetrating TraumaBlunt or Penetrating Trauma

Prehospital SBP Prehospital SBP – < 70 or < 70 or – SBP 70 - 90 & HR > 108/minSBP 70 - 90 & HR > 108/min

Age Age >>15yrs or >50kg15yrs or >50kg

Who?Who?

TBI Cohort Inclusion Criteria:TBI Cohort Inclusion Criteria: Blunt traumaBlunt trauma

Prehospital GCS Prehospital GCS < < 8 and 8 and prehospital SBP >90 mmHgprehospital SBP >90 mmHg

Age Age >>15yrs or >50kg15yrs or >50kg

What is Being Asked of What is Being Asked of the You?the You?

Registry: Identify Registry patients Registry: Identify Registry patients

CPR: Pads on patient; 50 or 300 compressions / CPR: Pads on patient; 50 or 300 compressions / analyzeanalyze

ITV: Attach valve to mask or ET tubeITV: Attach valve to mask or ET tube

Hypertonic Saline: Piggy back 250 ml bag / bolusHypertonic Saline: Piggy back 250 ml bag / bolus

Common to all Studies: Data Collection Sheet Common to all Studies: Data Collection Sheet

Keeping You in the Keeping You in the LoopLoop

The Research WireThe Research Wire

www.prehospitalresearch.www.prehospitalresearch.comcom

Username & PasswordUsername & Password

Paramedic ResourcesParamedic Resources

Thank You!Thank You!