CBT Instructors Workshop

Today’s Topics

State of King County EMS1

2 CPR: Then and Now

New CPR Guidelines3

ROC Study4

State of King County EMS2006

Mickey Eisenberg, MD, PhDMedical Program Director

1

What We Have Accomplished?

Population & BLS Call Volume

1.50

1.55

1.60

1.65

1.70

1.75

1.80

1.85

2001 2002 2003 2004 2005

Po

pu

lati

on

(m

illi

on

s)

50

70

90

110

130

150

170

BL

S C

all

Vo

lum

e (

tho

us

an

ds

)

Population BLS Call Volume

1

Number of Responses by Hour of the Day

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Hour of the Day

ALS Responses

BLS Responses

Time of Response1

BLS

Number of Responses: 162,510

Avg. Response Times: Total Unit

Minutes 6.0 4.7

6 Minutes or less 72.2% 84.1%

8 Minutes or less

10 Minutes or less

12 Minutes or less

14 Minutes or less

Cancelled Enroute Calls 2.2%

1

Age Distribution ALS & EMS Age Distribution

0

2000

4000

6000

8000

10000

12000

Age

ALS Responses

BLS Responses

1

Responses by TypeALS BLS

Cardiac 10,846 (26%) 12,823 (10%)

Respiratory 6,144 (15%) 11,875 (9%)

Neurological 5,942 (14%) 18,406 (14%)

Trauma 4,333 (10%) 36,855 (29%)

Abdominal/Genito-Urinary

Metabolic/EndocrineAlcohol/DrugPsychiatricAnaphylaxis/AllergyObstetric/

Gynecological

2,304 (6%)2,105 (5%)1,607 (4%)1,403 (3%)426 (1%)420 (1%)

9,132 (7%)3,719 (3%)5410 (4%)6598 (5%)1774 (1%)1038 (1%)

Other Illness 6,162 (15%) 21,480 (17%)

Total 41,692 129,110

1

LocationALS BLS

Home/Residence 23,590 (58%) 72,844 (53%)

Nursing Home/Adult Family Home

3,476 (9%) 8,919 (6%)

Clinic/MD Office 2,007 (5%) 3,099 (2%)

Other/Unknown Location

11,680 (29%) 54,397 (39%)

Total 40,753 139,259

1

Cardiac Arrest

Total number of cardiac arrests for all causes with resuscitation attempted:

Total number of cardiac arrests for all causes with resuscitation attempted:

YEAR #

2001 1141

2002 1147

2003 1093

2004 1087

2005 1124

1

Survival

36

31

3734

45

0

5

10

15

20

25

30

35

40

45

50

2001 2002 2003 2004 2005Year

Per

cent

Sur

viva

l

1

Past Year

• Infectious Disease Plan• ROC infrastructure established• CPR/Defibrillation protocol changed• EMT naloxone

1

EMT Naloxone

Study of potential benefit of EMT naloxone for narcotic overdose:

• 164 patients received naloxone for OD in one year.

• Respiratory rate < 10 in 48%.• Good response in 73%.• Uneven distribution among departments.• Agitation/combativeness in 15%, emesis

in 6%.

1

Past Year

• Infectious Disease Plan• ROC infrastructure established• CPR/Defibrillation protocol

continuation• EMT naloxone• SPHERE pilot

1

JEMS: June 20061

SPHERE Pilot

• South King Fire and Rescue, Kent, Port of Seattle, Auburn

• Comparison of alert (given by EMTs) versus letter sent by medical director

• Follow-up phone call

1

SPHERE Pilot

The City of Kent F ire Department took your blood pressure during your medical emergency. Your blood pressure was very high.

High blood pressure can lead to life-

threatening disease such as heart

disease or stroke or kidney failure. There are effective treatments for lowering high blood pressure. You need to discuss this with a doctor.

We recommend that you contact a doctor to have your blood pressure checked again as soon as possible. We may call you in a week or two to find out how you are doing.

Systolic

120

140

160

Diastolic

80

90

100

Normal

Pre- hy pertension

Hy pertension Stage 1


Blood Pressure Categories Date: ___________________________

EMT: ___________________________

Your blood pressure:

Sy stolic: __________ Diastolic: _________

FOLD

For more information on high blood pressure, you can call the American

Heart Association

1-800-AHA-USA-1 (1-800-242-8721)

or go online to

www.americanheart.org

High Blood

Pressure Alert

1

SPHERE PilotPatient Characteristics

Patients identified for the alert pilot had an average systolic blood

pressure of 175, and an average diastolic blood pressure of 94.

Patients identified for the alert pilot had an average systolic blood

pressure of 175, and an average diastolic blood pressure of 94.

1

SPHERE PilotPatient Comments

• One patient noted that she “absolutely loved” the firefighters.

• Another patient appreciated being told about her blood pressure and said that it was “valuable information” for those who have elevated BP and don’t know it.

• Another patient commented on the firefighters’ “excellent job.”

1

SPHERE PilotPreliminary Findings

• 65% of patients interviewed said the firefighter influenced them to see a doctor.

• 68% of patients interviewed said the firefighter influenced them to get their blood pressure rechecked.

• 94% of patients interviewed were pleased that the firefighter told them their blood pressure was elevated.

• Alert seemed to have more influence compared to letter.

1

New Projects for 2007

SPHERE (Supporting Public Health with Emergency Responders)

• Expand to entire county. • Use of routinely collected information to

give useful health information to patients

• Duty to inform patients• Hypertension and diabetes

1

SPHERE: Standard of Care in King County for 2007

Alerts and after-care instructions:• High blood pressure alert• High blood sugar alert• Low blood sugar after-care

instruction

1

High Blood Pressure Alert

Eligible patients:• Systolic BP > 160 or• Diastolic BP > 100

Not eligible:• Paramedic transported

patients• Nursing home patients

1

The City of Kent F ire Department took your blood pressure during your medical emergency. Your blood pressure was very high.

High blood pressure can lead to life-threatening disease such as heart disease or stroke or kidney failure. There are effective treatments for lowering high blood pressure. You need to discuss this with a doctor.

We recommend that you contact a doctor to have your blood pressure checked again as soon as possible. We may call you in a week or two to find out how you are doing.

Systolic

120

140

160

Diastolic

80

90

100

Normal

Pre- hy pertension



Blood Pressure Categories Date: ___________________________

EMT: ___________________________

Your blood pressure:

Sy stolic: __________ Diastolic: _________

FOLD

For more information on high blood pressure, you can call the American

Heart Association

1-800-AHA-USA-1 (1-800-242-8721)

or go online to

www.americanheart.org

High Blood

Pressure Alert

Documentation is mandatory.Documentation is mandatory.

High Blood Sugar Alert1

For more information on high blood sugar,

you can call the

American Diabetes Association

1-800-DIABETES (1-800-342-2383)

or go online to

www.diabetes.org

High Blood Sugar Alert

The City of Kent Fire Department measured your non-fasting blood sugar during your medical emergency. Your blood sugar level was very high.

Without proper treatment, high

blood sugar can lead to heart

disease, kidney disease, and

nerve damage. There are effective ways to manage high blood sugar. You need to discuss

th is with a doctor. We recommend that you

contact a doctor to have your

blood sugar level checked

again as soon as possible.

Date: _______________________

EMT: _______________________

Your blood sugar: ________

We may call you in a week or tw o to find out how you are doing.

FOLD

175

Possible diabetes

Non-diabetic

Diabetic

300

Better control needed

Non-Fasting Blood Sugar Guidelines

Eligible patients:• Diabetic: BS > 300• Non-diabetic: BS >175

Not eligible:• Paramedic transported

patients• Nursing home patients


Low Blood Sugar After-Care Instructions

Eligible patients: • Patients on insulin • Low blood sugar • Respond fully to

therapy

1

Date: ___________________

EMT:____________________

Low Blood Sugar After Care Instructions

If you have any comments or questions, please call your

local Fire Department during normal business hours.

For more information on low blood sugar,

you can call the

American Diabetes

Association

1-800-DIABETES (1-800-342-2383)

or go online to

www.diabetes.org

After administration of glucose and/or prior to the departure of the EMS Team, y our blood sugar lev el w as _________ at _________ AM/PM.

Your hypoglycemic episod e was

treated by th e following method:

□ No T reatment

The EMTs gave no immediate treatment because_________________________

□ Oral Glucose _______ gm

□ Other ____________________

For follow-up purposes, this information may be shared with your private doctor.

FOLD

Your EMS Team measured y our blood sugar dur ing y our medic al emergency . Prior to treatment, y our blood sugar lev el w as _________ at _________ AM/PM.

If you are choosing to stay at home: Eat a FU LL MEAL N OW. C ontac t y our doctor before y ou

tak e y our nex t ins ulin dos e. If y ou are unable to c ontac t y our doctor, reduce y our nex t insul in dose by 25% . Keep trying to contact your doctor.

C heck y our blood sugar frequently for the nex t sev eral hours.

DO NOT : stay alone or driv e/operate dangerous machinery for the nex t six (6) hours

If y our condition w orsens or ini tial signs and sy mptoms return, CALL 911 IMMEDIAT ELY !


2007 EMT Evaluations Underway

• Study of glucagon for hypoglycemia• Study of left-at-scene patients

following treatment for hypoglycemia

1

Possible Future EMT Evaluations?

• EMS active screening for type II diabetes?

• Consider aspirin for acute coronary syndrome?

• SPHERE – How to achieve follow-up? Pilot in Renton, Bellevue, Shoreline

• SPHERE – Pilot to compare alert versus alert followed by reminder letter.

1

My Thanks

It is an honor to work with you all.

Dr. Mickey EisenbergMedical Director

And Finally

• Questions• Suggestions• Comments• Clarifications• Opinions• Orations

CPR: Then and Now

Mike Helbock, M.I.C.P., NREMT-PManager – EMS Training and Education

Seattle/King County

2

It’s all about history, learning and

and moving forward…

Seattle’s First Medic Unit “Moby Pig”

2

• New thoughts…. CPR compression/numbers

• “Quality” of CPR (DVD-R)• NEW airway obstruction techniques• Resuscitation Outcome Consortium

2So…what’s on the ‘New to Do”

list

New thoughts on the numbers

*One minute of CPR between shocks may not be enough…*One minute of CPR between shocks may not be enough…

2

CPR (and all of it’s friends)

• Disappointment in the lack of increased survival rates since the 70’s.

• Don’t be fooled…a round of CPR isn’t a minute! (closer to 40 seconds).

• AEDs can take between 5-28 seconds to detect a rhythm!

• Delivering up to 3 shocks can range between 39-90 seconds!

2

A Little Background

Each of the links in the chain of survival are important for resuscitation.

9-1-19-1-1 Early CPR

Early CPR

Early Defib

Early Defib

Timely ALS

Timely ALS

2

Background, continued

Though the emphasis has been placed on early and frequent defibrillation.


Early CPR

Early Defib

Early Defib

Timely ALS

Timely ALS

2

Valenzuela et al, Circulation 1997

Surv

iva

Surv

iva

ll

5 10 15 5 10 15 20 20Time (in minutes)

This emphasis makes sense because the chances of survival from ventricular fibrillation decrease 5% for every minute without defibrillation.

Background, continued2

Rea TD et al. Circulation

With the introduction of AEDs for use by the EMTs, response time to defibrillation decreased in King County.

With the introduction of AEDs for use by the EMTs, response time to defibrillation decreased in King County.

Min

ute

s

0

2

4

6

8

10

1977-81 1982-85 1986-89 1990-93 1994-971998-2001


Su

rviv

al

0

10

20

30

40

50

1977-81 1982-85 1986-89 1990-93 1994-971998-2001

We hoped the reduction in time to defibrillation would produce better survival results.


Su

rviv

al

0

10

20

30

40

50

1977-81 1982-85 1986-89 1990-93 1994-971998-2001

What actually happened:


1. Determine VF.

2. Stacked shocks.

3. Pulse check after each shock.

4. 1 minute of CPR and re-analyze.

AND………AND………


So we reviewed the AHA protocol which was:

2



Early CPR

Early Defib

Early Defib

Timely ALS

Timely ALS

We looked more closely at the relationship between CPR and defibrillation from a

physiological standpoint.

We looked more closely at the relationship between CPR and defibrillation from a

physiological standpoint.

2

What We Found

The shock alone is not enough.

The shock can reset the heart electrically but mechanically the heart still needs to pump blood.

CPR before and after the shock can help the mechanical action of the heart.

2

So…Out With the Old

The “old” AHA algorithm inadvertently increased the amount of time without the mechanical component of CPR.

Yet these activities were very low yield because:

• Only 10% needed a stacked shock, and • Only 2% had a pulse with the “after shock” pulse check.

2

In With the New

Eliminated stacked shocks.

The goal was to increase CPR especially during the period immediately following the shock.The goal was to increase CPR especially during the period immediately following the shock.

So we implemented a single shock – start CPR algorithm in January 2005.

Eliminated pulse check after shock.

Extended period of CPR following shock from 1 to 2 minutes.

2

Time to CPR after the shock decreased from 30 seconds to 6 seconds.

YEAR 96 97 98 99 00 01 02 03 04 05

% surviva

l31 39 32 30 36 35 31 34 33

46

Duration of CPR increased from 50 seconds to 95 seconds.

Survival to hospital discharge went from 33% to 46%.

What happened since the change?

2

*More “hands on”

*Less shocks

Summary

*More focus on “Quality CPR"

*New methods of resuscitation- cooling- ITD- mechanical devices

2

CAN WE DO EVEN CAN WE DO EVEN BETTER?BETTER?

Which brings us to the question:

New CPR Guidelines3

CPR First Study3

• Quantity of CPR…(how much?)• Quality of CPR…(how good?)• Interface between the AED and

defibrillation

CPR: Questions3

ADULTS:

30:2

ADULTS:

30:21 or 2 person CPR WITHOUT intubation

New CPR Guidelines3

Medics arrive and intubate

New CPR Guidelines3

ADULTS:

30:2

ADULTS:


“Continuous compressions” with 8-10 ventilations per minute.(1 breath/6-8 sec.)


New CPR Guidelines3


ADULTS:

30:2

ADULTS:


INFANTS/ CHILDREN:

15:2

INFANTS/ CHILDREN:

15:22 person CPR WITHOUT intubation (HCP)

New CPR Guidelines3


New CPR Guidelines3

INFANTS/ CHILDREN:

15:2

INFANTS/ CHILDREN:


New CPR Guidelines



3


INFANTS/ CHILDREN:

15:2

INFANTS/ CHILDREN:


CPR—Focus on Quality

• Depth of 1 1/2–2 inches (or more in larger people).

• Minimize interruptions in chest compressions.

• Rotate compressors every 2–3 minutes to minimize fatigue.

3

Depth of compressions

Ventilations

CPR—Focus on Quality3

• 30:2 prior to intubation.

• 8—10 ventilations per minute when intubated. (1 breath/6-8 sec).

• Inspiration phase of no more than 1 second.


Decompression


Ventilations


• Complete chest recoil after each compression.

REQUIRED!

Rate of compression


Decompression

Ventilations


• Push Hard / Push Fast

• (100/min)

Airway Obstruction

ADULTSand

CHILD

ADULTSand

CHILDForeign-body airway obstruction

New Airway Guidelines3

Abdominal thrusts(no change)

RESPONSIVE


ADULTSand

CHILD

ADULTSand


CPR with airway check(1 round)

UNRESPONSIVE


Abdominal thrusts(no change)

RESPONSIVE

ADULTSand

CHILD

ADULTSand



INFANTINFANT Foreign-body airway obstruction

5 Backslaps/Chest Thrusts(business as usual)

RESPONSIVE


Foreign-body airway obstruction INFANTINFANT

CPR with Airway CheckCPR with Airway Check(1 round)(1 round)


5 Backslaps/Chest Thrusts(business as usual)

RESPONSIVE

Foreign-body airway obstruction

UNRESPONSIVE

INFANTINFANT

Rescue Breathing


ADULTSADULTS Rescue breathing

10 to 12 breaths/minute(1 breath every 5-6 seconds)



Must obtain “chest rise”





CHILD / INFANT

CHILD / INFANT Rescue breathing



CHILD / INFANT


New Airway Guidelines

Must obtain “chest rise”

3


CHILD / INFANT


• Research, Research, Research…..• Shock early…shock often…shock a lot… is

out!• Cases of VF on decline.• Conversion with 1st shock 95%.• New studies are needed to help us

understand what may be right!

So…what are we doing about it?

3

The “ROC”

Welcome to the ROC4

R.O.C.

• Resuscitation Outcome Consortia• Federally Funded Data Collection

Study• Study Specific EMS Interventions

4

ROC Sites4

Seattle - selected coordination site

• National Institutes of Health

• Canadian Institutes of Health Research

• Defense Research & Development Canada

• American Heart Association

• Heart & Stroke - Canada

ROC Sponsors4

• Consortium of EMS providers and researchers focused on outcomes from cardiac arrest and trauma.

• Goal is to evaluate new approaches and treatments.

• EMS providers will be primarily responsible for conducting studies.

What is the ROC?4

The Cardiac Arm…

To determine outcomes in cardiac arrest when comparing…

Difference between CPR with the ITD and CPR with a sham valve.

Difference between CPR with the ITD and CPR with a sham valve.

1

Difference between analyze early and analyze late protocols.Difference between analyze early and analyze late protocols.2

Purpose of the Study4

• The heart may need to be "primed" before it can be defibrillated.

• CPR – especially chest compressions -primes the heart by filling it with oxygenated blood.

• How much priming does the heart need before the shock?

Analyze Early/Analyze Late4

Analyze Early:

– 1 round (30 compressions) of priming before AED analysis

– Business as usual in Seattle/King County

Analyze Late:

– Longer period of priming before AED analysis

– 3 minutes of CPR before first analysis

Analyze Early/Analyze Late4

• Impedance Threshold Device

• ITD is a circulation adjunct not a ventilation adjunct.

• Increases blood flow back to the heart during the recoil phase of chest compression.

ITD Valve4

• Maximizes the vacuum effect, pulling more blood back to the heart.

• Prevents air flow into chest during recoil.

• Which enables more forward blood flow with the next compression.

Purpose of an ITD Valve4

Can be used with:

• Bag-valve-mask

• Endotracheal tube (ETT)

ITD Valve with head strap ITD Valve without head strap

Using the ITD Valve4

and the and the quest quest

continuescontinues……

• Mickey Eisenberg, MD

• Tom Rea, MD• Leonared Cobb, MD• Michael Copass, MD• Michele Olsufka, RN• David Carlbom, MD

• Will Longstreth, MD• Steve Deem, MD• Peter Kudenchuk,

MD• Charles Maynard,

PhD• Billy Reuben• Medic One

Foundation

Acknowledgments

Mike Helbock

206-423-4674

[email protected]

CBT Instructors Workshop

Documents

Transcript of CBT Instructors Workshop