Pre Hospital Resuscitation

Pre-hospital Pre-hospital ResuscitationResuscitation

K.S. ChewK.S. Chew

School of Medical Sciences,School of Medical Sciences,

Universiti Sains MalaysiaUniversiti Sains Malaysia

What’s new after “Guidelines 2005”?

IntroductionIntroduction

(Cummins et al. 1991)

Chain of Survival

Early Early Recognition Recognition and Activation and Activation of EMSof EMS

Early Early CPRCPR

Early Early DefibrillatiDefibrillationon

Early ALSEarly ALS

What This Talk IS NOTWhat This Talk IS NOT

IS NOT a cut and paste lecture from IS NOT a cut and paste lecture from AHA/ILCOR Guidelines 2005AHA/ILCOR Guidelines 2005

IS NOT a description about the IS NOT a description about the Malaysian prehospital scenario per seMalaysian prehospital scenario per se

IS NOT a critical appraisal on IS NOT a critical appraisal on scientific articlesscientific articles

Another piece of evidence? But…does it fit??

Four Main Key Four Main Key PointsPoints

Key Point No. 1Key Point No. 1

We have good news – we are now We have good news – we are now back to a single emergency number back to a single emergency number 999999

But will the implementation be But will the implementation be translated to an improved, effective translated to an improved, effective prehospital communication? prehospital communication?

Prank callsPrank calls Multilingual?Multilingual?

Chest compression only CPR Chest compression only CPR (without mouth to mouth ventilation) (without mouth to mouth ventilation) is set to become more important in is set to become more important in the out of hospital settingthe out of hospital setting

That is a good news to us, especially That is a good news to us, especially in our cultural settingin our cultural setting



Energy levels in biphasic waveform Energy levels in biphasic waveform defibrillator is becoming more defibrillator is becoming more definite in the very near future – it definite in the very near future – it seems that higher energy (200J- seems that higher energy (200J- 300J - 360J) is associated with better 300J - 360J) is associated with better outcome if more than one shock outcome if more than one shock requiredrequired

Monophasic waveform is phasing outMonophasic waveform is phasing out


New evidence has shown that for New evidence has shown that for certain cases of cardiac arrest certain cases of cardiac arrest patients who collapsed in the out of patients who collapsed in the out of hospital setting, paramedics can hospital setting, paramedics can terminate the resuscitation effort terminate the resuscitation effort (even at BLS level only) because the (even at BLS level only) because the survival rate is very very low.survival rate is very very low.

Can this rule be applied in Malaysia?Can this rule be applied in Malaysia?

Early Early RecognitionRecognition

Early Recognition

About three-quarters of out-of-hospital cardiac arrests occur at home or private residences rather than in public places Iwami et al., (2006)

Resuscitation 69, 221-228

Are We Targeting Enough?

Bystander-initiated CPR most frequently takes place in public places such as the street (Herlitz et al., 1994)

How about the majority (up to 75%) of the cases of cardiac arrest that occur at home?

Early Activation Early Activation of EMSof 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 CallsPrank 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 CPREarly CPR

AHA/ILCOR Guidelines AHA/ILCOR Guidelines 20052005

Guidelines 2000Guidelines 2000

15:2 for adults15:2 for adults 5:1 for child5:1 for child

Guidelines 2005Guidelines 2005

One universal ratio One universal ratio 30:2 for ALL except 30:2 for ALL except neonatesneonates

Simplify CPR for Simplify CPR for learninglearning

Longer series of Longer series of uninterrupted uninterrupted chest chest compressions.compressions.

Chest Compression Only Chest Compression Only CPRCPR

Guidelines 2005:Guidelines 2005:

“…“….. encouraged to do compression-.. encouraged to do compression-only CPR if they are only CPR if they are unableunable or or unwillingunwilling to provide rescue breaths to provide rescue breaths (Class IIa), although the (Class IIa), although the best methodbest method of CPR is of CPR is compressionscompressions ….. ….. with with ventilationsventilations.”.”

Mouth To Mouth Mouth To Mouth BreathingBreathing

The kiss of life or the barrier to The kiss of life or the barrier to CPR?CPR?

Bystander CPR only performed in less Bystander CPR only performed in less than 1/3than 1/3rdrd of out of hospital cardiac of out of hospital cardiac arrestsarrests

Complicated techniqueComplicated technique Fear of transmission diseaseFear of transmission disease Cultural barrier in MalaysiaCultural barrier in Malaysia

SOS-KANTO StudySOS-KANTO Study

Prospective, multicenter, observationalProspective, multicenter, observational In Kanto region of JapanIn Kanto region of Japan Witnessed, out of hospital cardiac arrestWitnessed, out of hospital cardiac arrest Primary endpoint - favourable Primary endpoint - favourable

neurological outcomes at 30 days after neurological outcomes at 30 days after cardiac arrestcardiac arrest

Secondary endpoint – survival 30 days Secondary endpoint – survival 30 days after cardiac arrest after cardiac arrest

Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet 2007; 369 (9565):920-6.

Lancet 2007; 369 (9565):920-6

72%

18%

11%

Key Findings of SOS-Key Findings of SOS-KANTO StudyKANTO Study

Out of the 4068 adults who had out-of-Out of the 4068 adults who had out-of-hospital cardiac arrests: hospital cardiac arrests: 72% did not receive CPR from a bystander72% did not receive CPR from a bystander 18% received full CPR from a bystander, 18% received full CPR from a bystander,

and and 11% received chest compression alone from 11% received chest compression alone from

a bystander a bystander Any resuscitation is better than no Any resuscitation is better than no

resuscitation at all (in terms of resuscitation at all (in terms of favourable neurological outcome at 30 favourable neurological outcome at 30 days) [5% vs 2%, p<0.0001]days) [5% vs 2%, p<0.0001]

Chest compression only is better than Chest compression only is better than chest compression PLUS mouth to mouth chest compression PLUS mouth to mouth in these THREE subgroups of patients:in these THREE subgroups of patients: Those with Those with apneaapnea [6% vs 3% (p=0.0195)] [6% vs 3% (p=0.0195)] Those with a Those with a shockable rhythmshockable rhythm [19% vs 11% [19% vs 11%

(p=0.041)](p=0.041)] Those who received CPR Those who received CPR within 4 minuteswithin 4 minutes

[10% vs 5% (p=0.0221)][10% vs 5% (p=0.0221)] NO subgroup showed any benefit from the NO subgroup showed any benefit from the

addition of mouth to mouth breathingaddition of mouth to mouth breathing

Key Findings of SOS-Key Findings of SOS-KANTO StudyKANTO Study

Why Chest Compression Why Chest Compression Alone is Preferred for Alone is Preferred for

Bystander CPR?Bystander CPR? Advantages to the rescuerAdvantages to the rescuer Simplify techniqueSimplify technique More willing to performMore willing to perform

Advantages to the patientsAdvantages to the patients Less interruptions of essential chest Less interruptions of essential chest

compressioncompression Mouth-to-mouth may actually increase Mouth-to-mouth may actually increase

intrathoracic pressure and reduce venous intrathoracic pressure and reduce venous returnreturn

Ventilation maybe unnecessary especially Ventilation maybe unnecessary especially during initial stage when the oxygen tension is during initial stage when the oxygen tension is still adequatestill adequate

Prompt Guidelines Prompt Guidelines Revision?Revision?

““This finding (SOS-KANTO’s) is an This finding (SOS-KANTO’s) is an important piece of evidence that should important piece of evidence that should lead to a prompt interim revision of the lead to a prompt interim revision of the guidelines for out-of-hospital cardiac guidelines for out-of-hospital cardiac arrest. arrest. Eliminating the need for Eliminating the need for mouth-to-mouth ventilation will mouth-to-mouth ventilation will dramatically increase the occurrence dramatically increase the occurrence of bystander-initiated resuscitation of bystander-initiated resuscitation efforts and will increase survival.”efforts and will increase survival.” (Ewy 2007, in an editorial comment in (Ewy 2007, in an editorial comment in

Lancet)Lancet)

A Blanket Rule Doesn’t A Blanket Rule Doesn’t ApplyApply

““We should, for now, to follow the newer We should, for now, to follow the newer guidelines [guidelines 2005] of assisted guidelines [guidelines 2005] of assisted ventilations and chest compression ventilations and chest compression [meaning ratio [meaning ratio 30:230:2] for ] for respiratory respiratory arrestarrest (such as in drowning and drug (such as in drowning and drug overdose), but the guidelines should overdose), but the guidelines should promptly be changed to chest-promptly be changed to chest-compression alone for witnessed compression alone for witnessed unexpected sudden collapse…”unexpected sudden collapse…” (Ewy 2007, in an editorial comment in Lancet)(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

SOS-KANTO’s findings - a good news to SOS-KANTO’s findings - a good news to usus

Encourage more publicEncourage more public, not just to , not just to know, but also to be ready and willing to know, but also to be ready and willing to perform bystander CPRperform bystander CPR

IF steps simplified (chest compression IF steps simplified (chest compression only) – only) – knowledge can also be knowledge can also be disseminated to more public disseminated to more public membersmembers – e.g. through short – e.g. through short documentary clips in TV, etcdocumentary clips in TV, etc

The Challenges within the The Challenges within the Malaysian Context Malaysian Context

Early Early DefibrillationDefibrillation

AHA/ILCOR Guidelines AHA/ILCOR Guidelines 20052005

““The The optimal energyoptimal energy for for first-shockfirst-shock biphasic waveform defibrillation … has biphasic waveform defibrillation … has not not been determined”been determined”

““Multiple .. studies have failed to identify an Multiple .. studies have failed to identify an optimal biphasic energy level for first or optimal biphasic energy level for first or subsequent shocks. Therefore, it is subsequent shocks. Therefore, it is not not possible to make a definitive possible to make a definitive recommendations recommendations for the selected energy for the selected energy for first or subsequent biphasic defibrillation for first or subsequent biphasic defibrillation attempts.” attempts.”

Introduction: BIPHASIC Introduction: BIPHASIC TrialTrial

(Stiell et al. 2007)

BIPHASIC TrialBIPHASIC Trial Triple blinded (blinded to researcher, patient Triple blinded (blinded to researcher, patient

and healthcare provider)and healthcare provider) Randomized, Multicenter, Manufacturer-fundedRandomized, Multicenter, Manufacturer-funded Compare fixed lower energy (150J-150J-150J) or Compare fixed lower energy (150J-150J-150J) or

escalating higher energy level (200J-300J-360J)escalating higher energy level (200J-300J-360J) Primary outcomePrimary outcome – successful conversion to an – successful conversion to an

organized rhythmorganized rhythm Secondary outcomeSecondary outcome – termination of – termination of

VF/pulseless VT regardless of the post-shock VF/pulseless VT regardless of the post-shock rhythmrhythm

BIPHASIC TrialBIPHASIC Trial

BIPHASIC TrialBIPHASIC Trial

If only a single shock is required, NO DIFFERENCE either using a lower or higher energy level

BIPHASIC TrialBIPHASIC TrialWhen multiple shock required, then higher energy escalating level is better

Implications of Implications of BIPHASIC TrialBIPHASIC Trial

AHA/ILCOR Guidelines 2005 clearly AHA/ILCOR Guidelines 2005 clearly states that three stacked shocks are no states that three stacked shocks are no longer recommended (as per Guidelines longer recommended (as per Guidelines 2000)2000)

Rather, the Guidelines 2005 recommend Rather, the Guidelines 2005 recommend a high, single shock followed a high, single shock followed immediately by resuming chest immediately by resuming chest compressioncompression

This is to minimize delay in chest This is to minimize delay in chest compressioncompression

This study implies that if fixed lower This study implies that if fixed lower energy regimen is chosen, many patients energy regimen is chosen, many patients probably were still in VF while CPR is probably were still in VF while CPR is going ongoing on

Which means that there will be a need Which means that there will be a need for additional shocks; thus causing for additional shocks; thus causing interruptions in chest compressioninterruptions in chest compression

This seems to go against the This seems to go against the recommendation of AHA/ILCOR recommendation of AHA/ILCOR Guidelines 2005 of a single shock in Guidelines 2005 of a single shock in minimizing interruption??minimizing interruption??

Implications of Implications of BIPHASIC TrialBIPHASIC Trial

Back to square one?

Question we may need to answer in the future is

Should we start with ONE, SINGLE,

HIGHEST energy level for biphasicbiphasic

waveform?And what is that level of

energy?

Early ALSEarly ALS

Let’s Face the Reality!

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 (Vaillancourt and Stiell, 2004)

Even in large cities in US, the overall survival has been quoted as ~1% (Ewy 2006)

Which Patients Should Be Which Patients Should Be Transported Back?Transported Back?

““..resuscitation attempts should be ..resuscitation attempts should be terminated when the patient terminated when the patient remains in remains in asystole despite full asystole despite full advanced life advanced life supportsupport procedures for more than procedures for more than 20 20 minutesminutes”” Recognition of Life Extinct Recognition of Life Extinct (ROLE)(ROLE) Guidelines Guidelines

by the Joint Royal Colleges Ambulance Liason by the Joint Royal Colleges Ambulance Liason CommitteeCommittee

Then how about those with only Then how about those with only basic life basic life supportsupport measures given by the measures given by the paramedics and EMTs with the use of paramedics and EMTs with the use of AEDs?AEDs?

Termination of Termination of Resuscitation (TOR) Study Resuscitation (TOR) Study

In NEJM 2006, Morrison et al reported In NEJM 2006, Morrison et al reported their prospective validation of their their prospective validation of their previously published TOR clinical previously published TOR clinical prediction rule (developed in 2002) that prediction rule (developed in 2002) that was derived retrospectively.was derived retrospectively.

Morrison LJ, Visentin LM, Kiss A et al. Morrison LJ, Visentin LM, Kiss A et al. Validation of a rule for termination of Validation of a rule for termination of resuscitation in out-of-hospital cardiac resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2006; 355 (5):478-87.arrest. N Engl J Med 2006; 355 (5):478-87.

TOR Prediction ruleTOR Prediction rule

Termination of Termination of BLSBLS resuscitation should be resuscitation should be considered whenconsidered when

1.1. There was There was no ROSC at allno ROSC at all before transport before transport

2.2. No shocks indicated/givenNo shocks indicated/given before before transporttransport

3.3. It was It was not witnessed by the EMSnot witnessed by the EMS personnelpersonnel

The authors found that only 0.5% of The authors found that only 0.5% of patients survived if all THREE criteria are patients survived if all THREE criteria are presentpresent

Out of the 1240 patients, Out of the 1240 patients, 776 patients776 patients fulfilled criteria to apply the TOR rule.fulfilled criteria to apply the TOR rule.

Out of this 776 patients, only 4 Out of this 776 patients, only 4 survived (0.5%)survived (0.5%)

Positive Predictive value 99.5%Positive Predictive value 99.5% Specificity 90.2%Specificity 90.2%

TOR Prediction ruleTOR Prediction rule

ResultsResults

Disadvantages Of Disadvantages Of Transporting Refractory Transporting Refractory

Cardiac ArrestsCardiac Arrests Limits availability of EMS personnelLimits availability of EMS personnel Increasing patient’s waiting timeIncreasing patient’s waiting time Decreases availability of bedDecreases availability of bed Emergency lights and siren by ambulance Emergency lights and siren by ambulance

driver – pose risks to motorists, pedestrian, driver – pose risks to motorists, pedestrian, etcetc

EMS personnel performing interventions in EMS personnel performing interventions in a moving vehicle or engaged in a moving vehicle or engaged in resuscitation are at increased occupational resuscitation are at increased occupational biohazards riskbiohazards risk

Wasting Of Resources In Transporting A so called “Futile” Cardiac Arrest Case?

REALLY???

Guidelines remain Guidelines remain GuidelinesGuidelines

““In an editorial published more than 20 In an editorial published more than 20 years ago, Cummins and Eisenberg years ago, Cummins and Eisenberg suggested that prediction rules for the suggested that prediction rules for the termination of resuscitation efforts should termination of resuscitation efforts should remain advisoryremain advisory and that they should be and that they should be tempered by the clinical picture, taking tempered by the clinical picture, taking into account the very small into account the very small possibility of possibility of successful resuscitation when the successful resuscitation when the prediction rules suggest termination”prediction rules suggest termination” (Morrison et al. 2006)(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 Can TOR guidelines be applied in Malaysia?applied in Malaysia?

Yes and noYes and no Issues yet to be resolved:Issues yet to be resolved: For how long BLS continued before For how long BLS continued before

we call it off as no ROSC achieved?we call it off as no ROSC achieved? Who are in the ambulance? Any Who are in the ambulance? Any

doctor?doctor? Legal right/authority of paramedics Legal right/authority of paramedics

to declare deathto declare death

ConclusionConclusion

What Would The Future Be In The Area Of

Pre-hospital Resuscitation?

Within the Malaysian context?


Many more studies on chest Many more studies on chest compression alone bystander CPR compression alone bystander CPR expected to follow after SOS-KANTO expected to follow after SOS-KANTO studystudy

Chest compression alone CPR set to Chest compression alone CPR set to become more important in the out of become more important in the out of hospital setting; more definite hospital setting; more definite indications in the futureindications in the future


Energy regimen for biphasic Energy regimen for biphasic waveform defibrillator?waveform defibrillator?

Energy levels in biphasic waveform Energy levels in biphasic waveform defibrillator set to become more defibrillator set to become more definite in the very near futuredefinite in the very near future

Monophasic waveform is phasing outMonophasic waveform is phasing out More manufacturers will reconfigure More manufacturers will reconfigure

the energy level regiment in their the energy level regiment in their AED productAED 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 OwnA Tale of Our Very Own

ReferencesReferences Cummins RO, Ornato JP, Thies WH et al. Cummins RO, Ornato JP, Thies WH et al.

Improving survival from sudden cardiac Improving survival from sudden cardiac arrest: the "chain of survival" concept. A arrest: the "chain of survival" concept. A statement for health professionals from the statement for health professionals from the Advanced Cardiac Life Support Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Subcommittee and the Emergency Cardiac Care Committee, American Heart Care Committee, American Heart Association. Circulation 1991; 83 (5):1832-Association. Circulation 1991; 83 (5):1832-47.47.

Ewy GA. Cardiac arrest--guideline changes Ewy GA. Cardiac arrest--guideline changes urgently needed. Lancet 2007; 369 urgently needed. Lancet 2007; 369 (9565):882-4.(9565):882-4.

Stiell IG, Walker RG, Nesbitt LP et al. Stiell IG, Walker RG, Nesbitt LP et al. BIPHASIC Trial: a randomized BIPHASIC Trial: a randomized comparison of fixed lower versus comparison of fixed lower versus escalating higher energy levels for escalating higher energy levels for defibrillation in out-of-hospital cardiac defibrillation in out-of-hospital cardiac arrest. Circulation 2007; 115 (12):1511-7.arrest. Circulation 2007; 115 (12):1511-7.

2005 American Heart Association 2005 American Heart Association Guidelines for Cardiopulmonary Guidelines for Cardiopulmonary Resuscitation and Emergency Resuscitation and Emergency Cardiovascular Care. Circulation 2005; Cardiovascular Care. Circulation 2005; 112 (24 Suppl):IV1-203.112 (24 Suppl):IV1-203.

ReferencesReferences

ReferencesReferences

Ewy GA. Cardiac resuscitation--when Ewy GA. Cardiac resuscitation--when is enough enough? N Engl J Med is enough enough? N Engl J Med 2006; 355 (5):510-2.2006; 355 (5):510-2.

Morrison LJ, Visentin LM, Kiss A et Morrison LJ, Visentin LM, Kiss A et al. Validation of a rule for al. Validation of a rule for termination of resuscitation in out-termination of resuscitation in out-of-hospital cardiac arrest. N Engl J of-hospital cardiac arrest. N Engl J Med 2006; 355 (5):478-87.Med 2006; 355 (5):478-87.

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Pre Hospital Resuscitation