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Tyler F. Vadeboncoeur, MD College of Medicine, Mayo Clinic Mayo Clinic – Jacksonville, FL Save Hearts in Arizona Regis

The Survival Rate from Witnessed Ventricular Fibrillation Out-of-Hospital Cardiac Arrest is Superior with Passive Oxygen Insufflation Compared to Active Bag-Valve-Mask Ventilation. Tyler F. Vadeboncoeur, MD College of Medicine, Mayo Clinic Mayo Clinic – Jacksonville, FL

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Tyler F. Vadeboncoeur, MD College of Medicine, Mayo Clinic Mayo Clinic – Jacksonville, FL Save Hearts in Arizona Regis

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  1. The Survival Rate from Witnessed Ventricular Fibrillation Out-of-Hospital Cardiac Arrest is Superior with Passive Oxygen Insufflation Compared to Active Bag-Valve-Mask Ventilation Tyler F. Vadeboncoeur, MD College of Medicine, Mayo Clinic Mayo Clinic – Jacksonville, FL Save Hearts in Arizona Registry and Education SHARE

  2. Disclosures • No industry device or pharmaceutical relationships

  3. SHARE Team Bentley J. Bobrow, MD Lani Clark Vatsal Chikani, MPH Arthur B. Sanders, MD Karl B. Kern, MD Robert A. Berg, MD Gordon A. Ewy, MD

  4. Cardiocerebral Resuscitation Single shock if indicated without pulse check or rhythm analysis Single shock if indicated without pulse check or rhythm analysis Single shock without pulse check or rhythm analysis EMS arrival CCC Only• 200 chest compressions 200 chest compressions 200 chest compressions 200 chest compressions Analysis Analysis Analysis BVM or Passive Insufflation 15L NRB Begin IV Administer 1 mg IV Epinephrine Resume Standard ACLS Consider Endotracheal Intubation • If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis

  5. Ventilation Rate During Out-of-Hospital CPR • 13 out-of-hospital cardiac arrest patients • Ventilation rate measured during CPR • Average ventilation rate: 30±3 per minute (range 15-49) Aufderheide et al. Circulation 2004; 109:1960-5

  6. Adverse Effects of Positive Pressure Ventilation • During CPR for cardiac arrest, positive pressure ventilation increases intra-thoracic pressure, decreases venous return to the chest and decreases blood flow to the heart and to the brain Aufderheide T, Sigurdsson G, Pirrallo R, Yannopoulos D, McKnite S, Briesen Cv, Sparks C, Conrad C, Provo T, Lurie K. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004;109:1960-1965.

  7. Passive Oxygen Insufflation: Clinical Experience 50 40 30 20 10 0 48% p = 0.001 Neurologically normal survival (%) 15% CPR CCR Kellum, Kennedy, Ewy. Amer J Med 2006;119:335

  8. Initiation of Cardiocerebral Resuscitation in Arizona • Although Cardiocerebral Resuscitation (which includes passive oxygen insufflation) was instituted by Kellum et al. in Rock and Walworth Counties, Wisconsin, there was concern that if paramedic/firefighters in the Arizona SHARE program were told that they could not perform endotracheal intubation nor use bag-valve-mask ventilation, that they would not accept Cardiocerebral Resuscitation (CCR). • Accordingly, they were given a choice between passive oxygen insufflation and active bag-valve-mask ventilation.

  9. Hypothesis There would be no difference in survival to hospital discharge for adults with OHCA receiving passive oxygen insufflation and those receiving active bag-valve-mask ventilation as part of the Cardiocerebral Resuscitation EMS Protocol.

  10. Methods • Observational analysis from the prospectively collected SHARE database • IRB approval from the University of Arizona • 11 EMS agencies in Arizona utilizing CCR

  11. Methods: Inclusion Criteria • Age >18 years • Presumed cardiac etiology • Arrest prior to EMS arrival • No obvious signs of death or DNR/DNI

  12. Methods: Documentation Criteria for Airway Management Type • Passive oxygen insufflation • Documented use of a NRB • Active bag-valve-mask ventilation • Documented use of a BVM • Documented ventilation rate

  13. Methods: Outcome Measures • Primary • Survival to hospital discharge: passive oxygen insufflation vs. active bag-valve-mask ventilation • All patients • Witnessed collapse with VF on EMS arrival

  14. Methods: Statistical Analysis • Survival rate to hospital discharge for passive oxygen insufflation vs. active bag-valve-mask ventilation • Chi-square analysis • Logistic regression analysis to determine the survival association of victims receiving passive oxygen insufflation with victims receiving active bag-valve-mask ventilation • A full model was adjusted for age, gender, location of arrest, witnessed, bystander CPR, VF and EMS dispatch to arrival time interval

  15. Enrollment 3,329 Total OHCA 171 excluded: < 18 YOA 3,158 adult • 874 excluded • 673 non-cardiac • 139 EMS witnessed • 62 missing outcome 2,284 arrests of cardiac etiology 598 CCR 1,686 Routine ALS 206 passive 376 active

  16. Characteristic Active (n=376) Passive (n=206) P Value Mean age, years (SD) 65.5 (15.8) 66.4 (15.1) 0.498 Males, % (n) 67.0 (252) 71.4 (147) 0.281 Home location, % (n) 76.1 (286) 75.7 (156) 0.928 Bystander CPR performed, % (n) 42.6 (160) 35.0 (72) 0.073 Witnessed, % (n) 45.2 (170) 44.2 (91) 0.810 Ventricular fibrillation, % (n) 31.4 (118) 35.0 (72) 0.380 EMS dispatch to arrival time, mean minutes (SD) 5.3 (2.4) 5.0 (1.8) 0.515 Witnessed collapse to defibrillation time, mean minutes (SD) 13.0 (6.1) 14.3 (8.0) 0.867 ResultsCharacteristics of OHCA Victims SD = Standard deviation

  17. ResultsSurvival to Hospital Discharge from OHCA POI 21/46 50% 40% 30% 20% 10% 0% BVM P=.001 P=.144 45.7% % Survival to Hospital Discharge 14/77 24/206 30/376 11.7% 18.2% 8.0% Witnessed with VF All Cardiac Arrests

  18. Comparison of Major OutcomesOdds Ratios Outcomes POI vs. BVM Primary Survival to hospital discharge, % 8.0 vs. 11.7 Odds ratio (95% CI) 1.7 (0.9-3.1) Survival with witnessed VF, % 18.2 vs. 45.7 Odds ratio (95% CI) 5.7 (2.3-14.2) The model is adjusted for age, gender, location, bystander CPR, ventricular fibrillation, witnessed, and EMS dispatch to arrival interval

  19. Limitations • Not a RCT • Limited electronic data

  20. Discussion • Possible beneficial effects of passive oxygen insufflation: • Minimizes risks of hyperventilation • May enable providers to focus on chest compressions and epinephrine administration • May avoid gastric distention, vomiting and aspiration

  21. Future Directions • Ongoing data collection and monitoring • Further evaluation with electronic waveform data

  22. Conclusion - 1 Overall, there was no difference in the survival of adults with OHCA receiving passive oxygen insufflation compared to those receiving active bag-valve-mask ventilationduring Cardiocerebral Resuscitation in Arizona.

  23. Conclusion - 2 The survival rate of adults with witnessed VF OHCA was superior in victims receiving passive oxygen insufflation than in victims receiving active bag-valve-mask ventilationduring Cardiocerebral Resuscitation in Arizona.

  24. Acknowledgements • We are grateful to all the EMS providers in the state of Arizona participating in the SHARE program • This presentation is dedicated to the firefighters and paramedics who risk their lives everyday to save others

  25. Hayes MM, Ewy GA, Anavy ND, Hilwig RW, Sanders AB, Berg RA, Otto CW, Kern KB Continuous passive oxygen insufflation results in a similar outcome to positive pressure ventilation in a swine model of out-of-hospital ventricular fibrillation Resuscitation. 2007;74(2):357-365. Passive Oxygen Insufflation Not Worse Even When Ventilation Was Not Excessive

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