Ben Bobrow, MD Lani Clark Medical Director Research and QI Director azshare laniemail.arizona Arizo

1.  Ben Bobrow, MD Lani Clark Medical Director Research and QI Director www.azshare.gov lani@email.arizona.edu Arizona Department of Health Services Bureau of Emergency Medical Services & Trauma System

2. SHARE – Save Hearts in Arizona Registry and Education Prehospital Emergency Care in Press SHARE Program has 4 distinct and interrelated components: Public Education: community training in compression only (no mouth-to-mouth); familiarity with what an AED is and does. AED Registry: State registration of AEDs in public places or private homes. Registration is free and provides coverage for state statute requirements of a) medical oversight (Dr. Bobrow); b) approval of chosen training program (AHA, Red Cross or the free 1 hr. SHARE condensed curriculum); c) review of an AED use. EMS: Cardiac arrest data from participating Arizona fire departments and implementation of innovative improvements targeted at improving survival. ED: Cardiac Arrest Centers focused on improving survival from hospital and neurological outcome for cardiac arrest survivors through therapeutic hypothermia among other things.SHARE Program has 4 distinct and interrelated components: Public Education: community training in compression only (no mouth-to-mouth); familiarity with what an AED is and does. AED Registry: State registration of AEDs in public places or private homes. Registration is free and provides coverage for state statute requirements of a) medical oversight (Dr. Bobrow); b) approval of chosen training program (AHA, Red Cross or the free 1 hr. SHARE condensed curriculum); c) review of an AED use. EMS: Cardiac arrest data from participating Arizona fire departments and implementation of innovative improvements targeted at improving survival. ED: Cardiac Arrest Centers focused on improving survival from hospital and neurological outcome for cardiac arrest survivors through therapeutic hypothermia among other things.

3. Current SHARE participating Fire Departments. Those in yellow have transitioned to the CCR (Cardiocerebral Resuscitation) protocol developed by Sarver Heart Center and approved by ADHS. Current SHARE participating Fire Departments. Those in yellow have transitioned to the CCR (Cardiocerebral Resuscitation) protocol developed by Sarver Heart Center and approved by ADHS.

4. Sudden Cardiac Arrest (SCA) Approximately 400,000 SCA/YR in US Avg 18 SCA/day in AZ #1 cause of adult death in the US Critical/Quantifiable EMS function Test of entire EMS System Self explanatory ?Self explanatory ?

5. Different Approach to SCA OHCA is a major public health problem SHARE is a public health program to address this problem. We should maximize our resources and collaborations to improve survival In late 2004 we approached ADHS with our idea and they approved these bullet points. It is important to note that this designation makes the SHARE Program HIPAA exempt, thereby, protecting fire departments from backlash when sending patient identifying data to Lani.In late 2004 we approached ADHS with our idea and they approved these bullet points. It is important to note that this designation makes the SHARE Program HIPAA exempt, thereby, protecting fire departments from backlash when sending patient identifying data to Lani.

6. OHCA Survival in Arizona With so few survivors in our state, we felt compelled to make modifications to our protocol, based upon current evidence, and track the results closely.With so few survivors in our state, we felt compelled to make modifications to our protocol, based upon current evidence, and track the results closely.

7. Just about everything one can think of has been tried over the past few decades with very little impact on survival.Just about everything one can think of has been tried over the past few decades with very little impact on survival.

8. Major Determinants of Survival From Cardiac Arrest Early/Effective CPR Early Defibrillation Research has shown these to be the most important determinants of survival.Research has shown these to be the most important determinants of survival.

9. Three-Phase Model of Resuscitation We now know that cardiac arrest is not the same from beginning to end. There are actually distinct phases over time. During the first 4-5 minutes of a cardiac arrest approximately 70% of victims are in VF. During this “electrical phase,” rapid defibrillation is the most effective treatment. This is why AEDs in public places like airports have been so valuable. After about 5 minutes the fibrillating heart has used up much of its energy (ATP) and the left ventricle is relatively empty of blood. Shocking this situation most often results in asystole or PEA. During this “circulatory phase” good chest compressions for a period of time are necessary. Think of priming the pump before delivering a shock. After about 10 minutes, a fibrillating heart rarely continues. This is the “metabolic phase” and we currently have little we can do for this phase prehospital.We now know that cardiac arrest is not the same from beginning to end. There are actually distinct phases over time. During the first 4-5 minutes of a cardiac arrest approximately 70% of victims are in VF. During this “electrical phase,” rapid defibrillation is the most effective treatment. This is why AEDs in public places like airports have been so valuable. After about 5 minutes the fibrillating heart has used up much of its energy (ATP) and the left ventricle is relatively empty of blood. Shocking this situation most often results in asystole or PEA. During this “circulatory phase” good chest compressions for a period of time are necessary. Think of priming the pump before delivering a shock. After about 10 minutes, a fibrillating heart rarely continues. This is the “metabolic phase” and we currently have little we can do for this phase prehospital.

10. When we shock in the “electrical phase” we obtain these results. If you go to Chicago ~~ stay in the airport ?When we shock in the “electrical phase” we obtain these results. If you go to Chicago ~~ stay in the airport ?

11. Outcomes of Rapid Defibrillation by Security Officers after Cardiac Arrest in Casinos Survival rate 74 % in patients who received first shock within 3 minutes Survival rate 49 % in patients who received first shock after 3 minutes Intervals of no more than 3 minutes from collapse to defibrillation are necessary to achieve the highest survival rates If you go to Las Vegas, stay in the main casino areas ?If you go to Las Vegas, stay in the main casino areas ?

12. Bystander CPR 67% of all OHCA occur in the victim’s private residence and that only 15% occur in actual public areas. When “extended care and medical facilities” are excluded, the percentage of arrests occurring in private residences increases to 82%. Everyone needs to know what to do because it is most likely to happen in your or someone’s home.Everyone needs to know what to do because it is most likely to happen in your or someone’s home.

13. Typical cardiac arrest scenario: Victim collapses and is unresponsive “911” is called Wait for professional help to arrive 2/3 of all Cardiac Arrest victims in Arizona do NOT receive “Bystander” CPR WHY is this??? This is typically what happens, the public waits for you. By the time you arrive the person’s chance of survival has already been decreased by up to 60% or more. Why doesn’t anyone do more?This is typically what happens, the public waits for you. By the time you arrive the person’s chance of survival has already been decreased by up to 60% or more. Why doesn’t anyone do more?

14. Reasons forLow Rates of Bystander CPR #5 Lack of training (Time & Cost) #4 CPR as taught is a complex psychomotor task -fear of not getting it right #3 Public fear of harming victim #2 Fear of litigation #1 Reason no one wants to do CPR…. We are addressing lack of training due to time and cost by offering Arizona residents free training that takes less than ½ an hour. We have simplified the process so they can remember what to do. We remind them that they can do no harm, the person’s condition is critical and they can only help. The Good Samaritan Law in Arizona (and every state now) protects anyone who attempts to help someone in an emergency from liability. ANDWe are addressing lack of training due to time and cost by offering Arizona residents free training that takes less than ½ an hour. We have simplified the process so they can remember what to do. We remind them that they can do no harm, the person’s condition is critical and they can only help. The Good Samaritan Law in Arizona (and every state now) protects anyone who attempts to help someone in an emergency from liability. AND

15. Few rescuers wants to do Mouth-to-Mouth breathing! We have removed mouth-to-mouth ventilations completely from the process.We have removed mouth-to-mouth ventilations completely from the process.

16. Can We Simplify BLS for Bystanders? Eliminate Mouth-to-mouth Rescue Breathing!!Chest Compression-only BLS for Lay Persons

17. This has been studied extensively by the CPR research group at the Sarver Heart Center in University of Arizona 6 different published studies all show that in experiment models of out-of-hospital cardiac arrest in swine, survival is the same with continuous chest compression CPR and standard, ideal (2 breaths in 4 seconds) CPR

18. These are results from swine studies at Sarver Heart. Outcomes from Standard CPR and CCC are virtually no different. Doing nothing has dismal long term survival outcome. These are results from swine studies at Sarver Heart. Outcomes from Standard CPR and CCC are virtually no different. Doing nothing has dismal long term survival outcome.

19. EMS almost always arrive during the Circulatory Phase As far as EMS is concerned ~~ we have always treated VF as VF, really regardless of time. We now know that rapid defibrillation in the Circulatory Phase can be deadly. Perfusion prior to shock is critical during this phase.As far as EMS is concerned ~~ we have always treated VF as VF, really regardless of time. We now know that rapid defibrillation in the Circulatory Phase can be deadly. Perfusion prior to shock is critical during this phase.

20. Circulatory Phase The period of VF after the first 4-5 minutes is referred to as the CIRCULATORY phase and it appears that the critical intervention at this point is perfusing the myocardium.

21. For some time we have known that interrupting coronary perfusion pressure for any reason, including airway interventions, decreases survival in animals. During any interruption the coronary perfusion pressure drops to zero and it takes about 15 or more good compressions to get it back to the level where it will do some good. For some time we have known that interrupting coronary perfusion pressure for any reason, including airway interventions, decreases survival in animals. During any interruption the coronary perfusion pressure drops to zero and it takes about 15 or more good compressions to get it back to the level where it will do some good.

22. Standard CPR: 30:2 Interruption of chest compression/relaxation has direct effects on the amount of coronary perfusion pressure generated during the period of compression cycles. At the beginning of each cycle, the first 5-10 compressions are “building up“ the CPP gradient and is not optimal until at least one/third of the series is completed. With cessation of chest compressions this gradient falls off rapidly, returning to near zero within 5-10 seconds. When resumed, must start over. Interruption of chest compression/relaxation has direct effects on the amount of coronary perfusion pressure generated during the period of compression cycles. At the beginning of each cycle, the first 5-10 compressions are “building up“ the CPP gradient and is not optimal until at least one/third of the series is completed. With cessation of chest compressions this gradient falls off rapidly, returning to near zero within 5-10 seconds. When resumed, must start over.

23. Continuous Chest Compressions In pigs, a CPP of no more than 29 mmHg resulted in the best resuscitation. Too high +/- 40 mmHg resulted in CPR traumatic injury and too low as we know did no good.In pigs, a CPP of no more than 29 mmHg resulted in the best resuscitation. Too high +/- 40 mmHg resulted in CPR traumatic injury and too low as we know did no good.

24. Coronary Perfusion Pressure in Humans Study of 100 patients with 24 Hr. ROSC ROSC No ROSC Maximal CPP 26 + 8 8 + 10 Initial CPP 13 + 9 2 + 9 No ROSC when CPP < 15 mm Hg Coronary perfusion pressure = aortic diastolic pressure. The ascending aortic and right atrial pressure difference and is highest in the relaxation phase of a compression. Since chest compression/relaxation cycles are responsible for generation of blood flow to the heart, a decrease in delivered chest compression cycles can markedly decrease the total amount of myocardial perfusion generated with the resuscitation effort.Coronary perfusion pressure = aortic diastolic pressure. The ascending aortic and right atrial pressure difference and is highest in the relaxation phase of a compression. Since chest compression/relaxation cycles are responsible for generation of blood flow to the heart, a decrease in delivered chest compression cycles can markedly decrease the total amount of myocardial perfusion generated with the resuscitation effort.

25. Causes of Chest Compression InterruptionsFor EMS Providers Assessing patient (i.e., repeatedly) Preparing and/or Over Ventilation IV placement Intubation Changing Rescuers Defibrillation, particularly use of AEDs

26. What about Oxygen? VFCA: Lungs and arterial circulation full of oxygen Key is circulating the oxygen already there Experimental work has shown Arterial Sats remain acceptable for up to 10 min of CCC Respiratory Arrest-Different ! Ventilation crucial to replace Oxygen In our SHARE data over 75% of all adult arrests are cardiac, not respiratory in nature.In our SHARE data over 75% of all adult arrests are cardiac, not respiratory in nature.

27. Ventilation Rate during Out-of-Hospital CPR Aside from not being necessary, ventilating can result in over-ventilation which has been widely documented in both prehospital and hospital resuscitation efforts. Over-ventilation has the impact of impeding venous return, thus interfering with the benefits of good compressions.Aside from not being necessary, ventilating can result in over-ventilation which has been widely documented in both prehospital and hospital resuscitation efforts. Over-ventilation has the impact of impeding venous return, thus interfering with the benefits of good compressions.

28. Circulatory Phase Should CPR ever be done BEFORE Defib? YES If the arrest was not witnessed by EMS or the time from collapse is estimated to be 5 minutes or more.If the arrest was not witnessed by EMS or the time from collapse is estimated to be 5 minutes or more.

29. Seattle data. Short response times (<4 min.) show little difference between what is done first. Response times of >4 min. resulted in increased survival if chest compressions were done before shock.Seattle data. Short response times (<4 min.) show little difference between what is done first. Response times of >4 min. resulted in increased survival if chest compressions were done before shock.

30. Lars Wik in Norway found similar results.Lars Wik in Norway found similar results.

31. Second half of slide 30-31Second half of slide 30-31

32. 2005 AHA Guidelines “For adult OHCA that is not witnessed, rescuers may give a period of CPR before checking the rhythm and attempting defibrillation” (Class IIb) AHA recognized this fact with changes in their guidelines 2005.AHA recognized this fact with changes in their guidelines 2005.

33. CCR vs. ACLSFUNDAMENTAL DIFFERENCES For Adult Non-Traumatic Cardiac Arrest Order in which interventions are performed Specified Continuous Cardiac Compressions Faster more forceful compressions Compressions Before and After Defibrillation Early IV Epinephrine Delay intubation for first 3 rounds Airway: Face Mask 02 No Atropine for first 3 rounds How does the CCR protocol differ from the AHA guidelines 2005?How does the CCR protocol differ from the AHA guidelines 2005?

34. EPINEPHRINE Attempt to administer early IV epinephrine Intraosseous administration fastest One main difference is the administration of IV or IO Epi during the first, second and third set of compressions. This will make more sense when we get to the protocol slide.One main difference is the administration of IV or IO Epi during the first, second and third set of compressions. This will make more sense when we get to the protocol slide.

35. CCR vs. 2005 Guidelines Promotes CCC-CPR for layperson Passive oxygen insufflation Protocolizes 200 pre- and post-shock compressions Protocolize early IV/IO Epinephrine Protocolizes delayed ET intubation CCR protocolizes steps rather than making them optional.CCR protocolizes steps rather than making them optional.

36. Cardiocerebral Resuscitation (CCR) This is the Cardiocerebral Resuscitation protocol. -Chest compression alone CPR is advocated and instructed by 9-1-1 dispatchers. -If adequate bystander CPR is provided, paramedics go directly to rhythm analysis and shock if indicated. This is a judgment call by the EMS provider on scene who sees the actual CPR being done by bystanders. -If there is no bystander CPR, Paramedics administer 200 rapid, forceful, uninterrupted chest compressions at a rate of 100 compressions per minute allowing full chest recoil, without concern for presenting rhythm. -If a shockable rhythm is present, a single shock is administered followed immediately by another 200 chest compressions prior to pulse or rhythm check. -The airway is initially managed with either Active Bag-Valve-Mask ventilation at a rate of 8-10 ventilations/minute OR 15L Oxygen delivered via a Non Rebreather facemask. -The choice of ventilation technique is made by each EMS system. When available, Paramedics administer one milligram of epinephrine Intravenously as early as possible and again with each cycle of 200 chest compressions and rhythm analysis. If Return of Spontaneous Circulation is not achieved after 3 cycles of chest compressions and rhythm analysis, providers return to their standard ALS protocol consisting of endotracheal intubation and medications.This is the Cardiocerebral Resuscitation protocol. -Chest compression alone CPR is advocated and instructed by 9-1-1 dispatchers. -If adequate bystander CPR is provided, paramedics go directly to rhythm analysis and shock if indicated. This is a judgment call by the EMS provider on scene who sees the actual CPR being done by bystanders. -If there is no bystander CPR, Paramedics administer 200 rapid, forceful, uninterrupted chest compressions at a rate of 100 compressions per minute allowing full chest recoil, without concern for presenting rhythm. -If a shockable rhythm is present, a single shock is administered followed immediately by another 200 chest compressions prior to pulse or rhythm check. -The airway is initially managed with either Active Bag-Valve-Mask ventilation at a rate of 8-10 ventilations/minute OR 15L Oxygen delivered via a Non Rebreather facemask. -The choice of ventilation technique is made by each EMS system. When available, Paramedics administer one milligram of epinephrine Intravenously as early as possible and again with each cycle of 200 chest compressions and rhythm analysis. If Return of Spontaneous Circulation is not achieved after 3 cycles of chest compressions and rhythm analysis, providers return to their standard ALS protocol consisting of endotracheal intubation and medications.

37. Results: Mean Time Intervals SHARE data shows: Dispatch to arrival and transport intervals do not differ between those receiving CCR and Routine ALS. SHARE data shows: Dispatch to arrival and transport intervals do not differ between those receiving CCR and Routine ALS.

38. ResultsSurvival from Out of Hospital Cardiac Arrest These are the results we’ve seen so far and was presented at the AHA Conference in Florida in November: The overall (all presenting rhythms) survival rate to Hospital discharge for those receiving Routine ALS was 3.6% (the same 3% we found in 2004). The survival rate for those receiving Routine ALS who had a witnessed collapse and VF on EMS arrival was 10.9%. The overall survival rate for those receiving Cardiocerebral Resuscitation was 9.2% and for the subgroup with a witnessed collapse and VF on EMS arrival - 28.1%. Survival is defined as discharged from hospital home alive. The majority have good or excellent neurological status. These are the results we’ve seen so far and was presented at the AHA Conference in Florida in November: The overall (all presenting rhythms) survival rate to Hospital discharge for those receiving Routine ALS was 3.6% (the same 3% we found in 2004). The survival rate for those receiving Routine ALS who had a witnessed collapse and VF on EMS arrival was 10.9%. The overall survival rate for those receiving Cardiocerebral Resuscitation was 9.2% and for the subgroup with a witnessed collapse and VF on EMS arrival - 28.1%. Survival is defined as discharged from hospital home alive. The majority have good or excellent neurological status.

39. Witnessed VF Survival Passive Oxygen Insufflation vs. BVM Ventilation This is our survival data for witnessed VF when using the different oxygen delivery options.This is our survival data for witnessed VF when using the different oxygen delivery options.

40. Discussion: Possible Beneficial Effects of CCR Minimize interruptions of marginal forward blood flow during resuscitation efforts Minimize hyperventilation during resuscitation Delay of advanced airway interventions may enable providers to focus on compressions and earlier epinephrine administration Some possible reasons for CCR leading to the improved survival we measured include: - CCR Minimizes interruptions to marginal forward blood flow during resuscitation efforts. - Hyper-ventilation, which occurs frequently during standard resuscitation, is minimized with CCR. - Delay in performing advanced airway interventions may enable providers to focus on chest compressions and earlier epinephrine administration Likely it is a combination of these three factors.Some possible reasons for CCR leading to the improved survival we measured include: - CCR Minimizes interruptions to marginal forward blood flow during resuscitation efforts. - Hyper-ventilation, which occurs frequently during standard resuscitation, is minimized with CCR. - Delay in performing advanced airway interventions may enable providers to focus on chest compressions and earlier epinephrine administration Likely it is a combination of these three factors.

41. CCR Compliance 1) 200 pre-shock chest compressions 2) Delayed endotracheal intubation for three cycles of 200 compressions, rhythm analysis, shock if indicated and IV/IO Epi when possible 3) Attempted  intravenous epinephrine administration during the first or second series of chest compressions 4) 200 post shock chest compressions  In order for a patient to have received the CCR protocol, all 4 of these must have been adhered to. For EMT only systems #3 is not considered a requirement.In order for a patient to have received the CCR protocol, all 4 of these must have been adhered to. For EMT only systems #3 is not considered a requirement.

42. Actual Effectiveness of Cardiocerebral Resuscitation Depends upon Compliance!! Outcomes of patients who did and who did not receive all four critical CCR steps Protocol compliance has proved to be far more critical than initially assumed.Protocol compliance has proved to be far more critical than initially assumed.

43. Cardiocerebral ResuscitationProtocol Compliance 22% of patients did NOT receive CCR 78% of patients did receive CCR > ¾ of the incidents were determined compliant. The others had some but not all of the requirements present.> ¾ of the incidents were determined compliant. The others had some but not all of the requirements present.

44. Cardiocerebral ResuscitationProtocol Compliance 22% of patients did NOT receive CCR -8% survivors with witnessed VF 78% of patients DID receive CCR - 41% Witnessed VF survival Again, protocol compliance is critical to survival.Again, protocol compliance is critical to survival.

45. Cardiocerebral Resuscitation This is the Cardiocerebral Resuscitation protocol again. Chest compression alone CPR is advocated and instructed by 9-1-1 dispatchers. If adequate bystander chest compressions are provided, paramedics go directly to rhythm analysis and shock. If there is no bystander CPR, Paramedics administer 200 rapid forceful uninterrupted chest compressions at a rate of 100 compressions/minute allowing full chest recoil. If a shockable rhythm is present, a single shock is administered followed immediately by another 200 chest compressions prior to pulse or rhythm check. The airway is initially managed with either a BVM at a rate of 8 ventilations/minute or 100% FIO2 NRB facemask . This was left up to the paramedics discretion depending on how many providers were responding to the arrest. Paramedics administer one milligram of epinephrine Intravenously as early as possible and again with each cycle of chest compression and rhythm analysis. After 3 cycles of chest compressions and rhythm analysis, providers returned to their standard ACLS protocol consisting of endotracheal intubation and ACLS drugs.This is the Cardiocerebral Resuscitation protocol again. Chest compression alone CPR is advocated and instructed by 9-1-1 dispatchers. If adequate bystander chest compressions are provided, paramedics go directly to rhythm analysis and shock. If there is no bystander CPR, Paramedics administer 200 rapid forceful uninterrupted chest compressions at a rate of 100 compressions/minute allowing full chest recoil. If a shockable rhythm is present, a single shock is administered followed immediately by another 200 chest compressions prior to pulse or rhythm check. The airway is initially managed with either a BVM at a rate of 8 ventilations/minute or 100% FIO2 NRB facemask . This was left up to the paramedics discretion depending on how many providers were responding to the arrest. Paramedics administer one milligram of epinephrine Intravenously as early as possible and again with each cycle of chest compression and rhythm analysis. After 3 cycles of chest compressions and rhythm analysis, providers returned to their standard ACLS protocol consisting of endotracheal intubation and ACLS drugs.

47. SHARE and CCR Goal Optimal timing of defibrillation Reducing all “Hands-Off” Intervals Avoid hyper-ventilation Administer early IV/IO epinephrine Increase and maintain coronary perfusion pressure Increase % of bystander CPR Back to the basics!Back to the basics!

48. Most Common CCR Errors Stacked Shocks Early Endotracheal Intubation before 3 cycles completed Hyperventilation Late Administration of Epinephrine Omitting or delaying Post-Shock Compressions Administration of Other Meds (atropine) In review, these are the most common protocol errors. Some of it is just knee-jerk reaction to what you have been told to do for years. It will become second nature if you review it periodically.In review, these are the most common protocol errors. Some of it is just knee-jerk reaction to what you have been told to do for years. It will become second nature if you review it periodically.

49. Future of Cardiocerebral Resuscitation: We have experienced a tremendous improvement in survival with CCR without any information on the QUALITY of CHEST COMPRESSIONS Imagine what we could do with OPTIMAL rate, depth, and recoil.. Waveform Data Improved Protocol Compliance Improved Documentation Pay attention to your compressions ~~ they are truly important. Anyone who would like to go to Tucson and observe in the swine lab at SHC can contact Lani. It is interesting and one can learn how to do “perfect” compressions!Pay attention to your compressions ~~ they are truly important. Anyone who would like to go to Tucson and observe in the swine lab at SHC can contact Lani. It is interesting and one can learn how to do “perfect” compressions!

50. Where do we go from here? Compression-only CPR for laypeople – mass training EMS – more emphasis on uninterrupted chest compressions In-hospital – Cardiac Arrest Center concept Children – prevent arrest Current goals for SHARECurrent goals for SHARE

51. DOCUMENTATION Complete and accurate documentation is critical to know the success of your efforts! The following data is required IN ADDITION to your standard, current documentation ------ No one likes to hear this but it’s true! What you document is what happened ……… or not.No one likes to hear this but it’s true! What you document is what happened ……… or not.

52. ADDITIONAL DATA Write “CCR” if you intended to do protocol Bystander CPR – type (CCC/CPR) and quality, by whom CCC – # compressions pre and post shock, how many cycles When was IV Epi #1 given and how Ventilation – method and rate At what point in resuscitation was intubation attempted / accomplished Patient’s condition when you went back in service Ethnicity Electronic data collection is the goal! Patient Medical Record Number if possible Note: The patient medical record allows SHARE to combine YOUR patient with his/her in hospital stay. This has not regularly been requested but would be a great help so if you can obtain it before you go back in service it is appreciated.Note: The patient medical record allows SHARE to combine YOUR patient with his/her in hospital stay. This has not regularly been requested but would be a great help so if you can obtain it before you go back in service it is appreciated.

53. Deaths Post Resuscitation Many post-ROSC patients die About 1/3 are from CNS injury About 1/3 from Myocardial injury And about 1/3 from variety of causes (i.e., infection, etc.) Schoenenberger et. al., Arch Intern Med 1992;154:2433 Even patient who have ROSC in the field don’t make it to discharge. Why?Even patient who have ROSC in the field don’t make it to discharge. Why?

54. We now have the hospitals involved. Currently University Medical Center in Tucson and Mayo Clinic Hospital in Scottsdale are the only two hospitals in the state that administer therapeutic hypothermia. This is the cooling of the body’s core temperature to protect the brain from damage.We now have the hospitals involved. Currently University Medical Center in Tucson and Mayo Clinic Hospital in Scottsdale are the only two hospitals in the state that administer therapeutic hypothermia. This is the cooling of the body’s core temperature to protect the brain from damage.

55. Recommendations Unconscious adult patients with return of spontaneous circulation (ROSC) after out-of hospital cardiac arrest should be cooled to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours when the initial rhythm was ventricular fibrillation. Class IIa Similar therapy may be beneficial for patients with non-VF arrest out of hospital or for in-hospital arrest. Class IIb Therapeutic hypothermia. More and more hospitals are expressing interest and gearing up to provide this technology. We have established a “Cardiac Arrest Center” template in Arizona and encouraging any hospital who wishes to participate to come on board.Therapeutic hypothermia. More and more hospitals are expressing interest and gearing up to provide this technology. We have established a “Cardiac Arrest Center” template in Arizona and encouraging any hospital who wishes to participate to come on board.

56. Cardiac Arrest CentersOur Vision for Arizona Cardiac arrest centers are hospitals that provide hypothermia initiated in the ED, have cath lab facility 24/7, and the round the clock ability to provide cardiac arrest victims who achieve a return of pulse in the field with the optimum care.Cardiac arrest centers are hospitals that provide hypothermia initiated in the ED, have cath lab facility 24/7, and the round the clock ability to provide cardiac arrest victims who achieve a return of pulse in the field with the optimum care.

57. EMS Post Resuscitation Care Support Ventilation Ventilation Rate of 8-10/minute 12-lead ECG with Prenotification if STEMI COLD IV Normal Saline Fluid Bolus (500cc) Do NOT actively WARM Patient Consider Anti-Arrhythmic Drug-Lidocaine, Amiodarone, Magnesium Transport to a Cardiac Arrest Center when practical Our SHARE ideal for those patients who achieve ROSC in the field.Our SHARE ideal for those patients who achieve ROSC in the field.

58. AZ EMS Partnership: Participate in SHARE – let’s work together Suggestions always welcome! Teach your communities to do CCC-CPR in mass – PowerPoint available from SHARE

59. What is at Stake? 1000 OHCA patients in VF Baseline survival rate of 7% = 70 lives Goal survival rate of at least 34% = 340 lives We can potentially save over 270 Additional Lives Per Year! We have approximately 6,000 cardiac arrests in Arizona per year. This is probably an underestimate.We have approximately 6,000 cardiac arrests in Arizona per year. This is probably an underestimate.

60. Common Questions Is this standard of care? What about children? What about trauma, OD, drowning? Is this a research study? What does the AHA say about this? It is a standard of care in Arizona. Also, now parts of Wisconsin, Kansas City, and we get requests daily from places wanting to implement CCR. However, most are unable to collect the necessary data to know where there are starting so they can measure improvement. Arizona is uniquely blessed with the ability to accomplish this daunting feat. Children under 8 are generally respiratory arrest in nature. They should be ventilated according to AHA guidelines. Trauma, OD, and drowning should also be treated with the appropriate protocol. This is not a research study. It is a successful public health program. The AHA awarded us the “Abstract of the Year 2007 Award” at their international meeting in November. Many of the cardiologists at SHC are active and respected members of AHA and AHA is impressed with what we are doing. We anticipate seeing some changes in the 2010 Guidelines! Maybe wishful thinking…….It is a standard of care in Arizona. Also, now parts of Wisconsin, Kansas City, and we get requests daily from places wanting to implement CCR. However, most are unable to collect the necessary data to know where there are starting so they can measure improvement. Arizona is uniquely blessed with the ability to accomplish this daunting feat. Children under 8 are generally respiratory arrest in nature. They should be ventilated according to AHA guidelines. Trauma, OD, and drowning should also be treated with the appropriate protocol. This is not a research study. It is a successful public health program. The AHA awarded us the “Abstract of the Year 2007 Award” at their international meeting in November. Many of the cardiologists at SHC are active and respected members of AHA and AHA is impressed with what we are doing. We anticipate seeing some changes in the 2010 Guidelines! Maybe wishful thinking…….

61. Please go to the SHARE website: www.azshare.gov regularly. We try to keep it up to date for the public, EMS and ED personnel.Please go to the SHARE website: www.azshare.gov regularly. We try to keep it up to date for the public, EMS and ED personnel.

62. Acknowledgements We are grateful to all the EMS providers in Arizona participating in the SHARE Program. We are grateful to all the EMS providers in Arizona participating in the SHARE Program.