The importance of a ‘resuscitation recipe’
Ho, ho, ho! After completing a practice run to prepare for my annual trek across the world on Christmas Eve-something I do to ensure I don’t miss any homes and to get the reindeer in shape for the long journey-I sat down to debrief with my reindeer and elves.
The trial run turned out to be a good opportunity to test out the new oscillating red LED nose that Rudolph had implanted in the off- season, and the micro-drones we’ll be deploying to speed up the delivery of gifts this year.
At the postflight meeting, I asked my hardworking reindeer to load up lots of presents that I want to give EMS systems to use as soon as possible; things like: citizen alert software, CPR feedback devices, end-tidal CO2 monitors, airway assistance devices, mechanical CPR devices and some compact extracorporeal membrane oxygenation (ECMO) devices for EDs, aeromedical services and forward-thinking hospital/ prehospital response systems.
I also asked the elves to mark multiple addresses to ensure the delivery of extra cookies and gifts to EMS agencies and personnel who have truly excelled in their resuscitation research, clinical work and operational changes.
They all dutifully agreed to carry out their assignments, but several said they had questions they’d like me to address.
Why so Few?
The main question the elves had was why there were so few places on my list who had earned the extra cookies and presents for their resuscitation efforts.
I told them that, sadly, most EMS and fire agencies are still using traditional or obsolete methods for patient resuscitation and, as on old, chubby guy at risk for cardiac arrest, I want to reward those who have the best chance of resuscitating me if I collapse in their service area.
A few of the reindeer questioned why I was going to be giving out extra resuscitation tools at all, since the reindeer chatter in the stable was that it’s impossible to achieve a return of spontaneous circulation (ROSC) rate greater than 10%.
“Ho Ho Ho, NO NO NO!” was my immediate reply. I added, “You dedicated, beautiful hoofed helpers are misinformed and have fallen into the false belief that many have fallen into: that 10-20% ROSC is the best we can do. In fact, there are currently services achieving ROSC 40-70% of the time.”
Donner giggled, Prancer pranced, Dasher snorted and Vixen blurted out, “That’s a bunch of reindeer poop, Santa! No one’s achieving 40-70% ROSC!”
My face turned as red as my red velvet suit. I opened my iPad and began to show them EMS systems that were achieving not just 40-70% ROSC, but experiencing patients walking out of the hospital neurologically intact after several hours on mechanical compression devices and several days on ECMO.
They still didn’t believe me, so I sent them off to the workshop while I pondered how to get my resuscitation message across to them.
I felt bad for upsetting them, but I was frustrated because they held archaic impressions of what was acceptable. I could convince them to modernize the time-consuming practice of whittling toys for children by using computers and 3-D printers, but I couldn’t convince them that old resuscitation practices were no longer cutting the mustard!
The Lightbulb Moment
I sat down on my red velvet recliner to relax and take a long winter’s nap. But before dozing off, I watched Mrs. Claus bake cookies and special holiday treats with our granddaughters, Hinley and Harper.
Like I do with my detailed preflight step-by-step checklists, I heard her tell the girls what ingredients to put into the bowl, as well as how much to put in.
They wanted to deviate from the proven recipe and do it “their way,” but Mrs. Claus told them, “Girls, you have to understand that if you don’t use the exact ingredients called for by the recipe, in the right order, and at the right temperature, you won’t get the desired results!”
It hit me like a ton of bricks falling off a snow-covered roof! Mrs. Claus could be describing what must happen to get the desired results during resuscitations: Use a preplanned, proven recipe with the right ingredients in the right order, to get the desired results!
Santa’s Resuscitation Rhyme
I rose to my feet so fast that my phone fell to the floor with a clatter,
I raced outside, anxious to tell them all about the important matter.
“Get off your shelves my sleepy little elves, and assemble really quick!
Come Dasher, come Dancer, come Prancer and Vixen, to hear from jolly ol’ Saint Nick!
Come Comet, come Cupid, come Donner and Blitzen!
Hey Rudolph, stop texting and come over and listen!”
They gathered around me that cold winter night,
anxious to learn whatever they might.
“Experts now know the secret to saving a life,
Is quite like the advice of my beautiful wife.
You can’t rely on one ingredient in a bowl;
Success lies in the careful sum of the whole.”
“While studies are great and some think each one’s ideal,
It’s their combined impact where improved results reveal.
Studies may show we can compete with machines that compress,
But consistency of effort is what so few fail to address.”
“Blood flow to the brain is the key, you must see.
If it’s interrupted, the patient’s demise it’ll be.
The heart is a pump that needs consistent blood flow.
If we’re without it–forget it! No oxygen will go.”
“If you stray from the process, like when making great dough,
out the window your save rate surely will go!”
Although not yet that old, Rudolph was bold,
and asked what the boxes I was carrying did hold.
“The boxes, you see, are chock full of resuscitation pearls:
A JEMS issue and supplement to help countless boys and girls.”
“The content,” I said, “when carefully read,
Can keep people alive who would otherwise be dead.”
They asked me to impart the knowledge I bared,
So I sat them all down and slowly I shared.
I read them key excerpts the JEMS experts had gathered,
and cited passages of text, as well as the data that mattered.
“Like the tips from my wife,” I told them that night,
“The gifts that we’re giving could help save a life.”
I passed around JEMS and had them review,
The articles that would forever change the work that we do.
The multiple key articles I present to you here,
Contain lessons and processes I pray you’ll truly hold dear!
An Overview of the December 2017 Issue & Resuscitation Supplement
Dr. Karl B. Kern, MD, sets the tone for the December JEMS focus on resuscitation in his article Trends & Changes in Cardiac Resuscitation: Current best practices for refractory ventricular fibrillation cardiac arrest. He points out that all EMS systems occasionally see at least one subgroup with even less chance of survival, those with refractory ventricular fibrillation (v fib) cardiac arrest yet the typical approach to these refractory cardiac arrest patients has simply been “more of the same;” – continued CPR, repeated defibrillation attempts and administration of ACLS medications. His introductory article will show you why we must begin to think differently in our approach to resuscitation in the future.
In Double Defibrillation: Do or die? Peter J. Kudenchuk, MD, discusses double defibrillation, harnessing two defibrillators to administer simultaneous or double sequential shocks (sometimes called the “one-two punch”), and notes that though well-intentioned and considered by some as an innovative approach to treating shock-resistant ventricular fibrillation (v fib), biphasic double defibrillation is also controversial, off-label and poorly studied.
In ECMO & Refractory OHCA: The dawn of a new era, Demetris Yannopoulos, MD, who established the first ECMO-based resuscitation protocol in the U.S. for refractory v fib out-of-hospital cardiac arrest patients, explains the how eripheral veno-arterial ECMO is being used during CPR in specialty centers, in emergency departments and even on the streets in some countries, started by specialty ECMO teams.
His article shows, through significant studies and data, how ECPR and ECMO use in the post-resuscitation management of patients of OHCA refractory cardiac arrest has yielded highly promising results by providing a therapeutic platform that, when applied early and within 60 minutes from the 9-1-1 call, can potentially double survival.
He notes that the advancement of automated CPR devices, such as the LUCAS and Autopulse, has revolutionized the way that refractory cardiac arrest patients can be treated with either longer periods of CPR or with early mobilization strategies where the patient now can be transferred to an advanced resuscitation center for ECPR initiation and coronary angiography and possible percutaneous coronary intervention (PCI).
In ECMO & ECPR: The new load & go destination for cardiac arrest?, Dr Scott T. Youngquist and his co-authors explain ECMO’s effectiveness as a bridge for a reversible or recoverable insult that is otherwise refractory to conventional management. By bypassing the entire cardiopulmonary system, the heart is allowed time to recover from an insult while systemic perfusion and oxygenation to the whole body are maintained.
In Prehospital Cath Lab Activation: Alerts for witnessed, shockable cardiac arrest yield dramatic results in Lincoln, Lincoln Nebraska Fire & Rescue (LFR) Medical Director Jason Kruger, MD and Scott Wiebe, EMT-P, outline the journey by this progressive fire service to partner with community stakeholders to initiate a comprehensive effort to improve survival from sudden out-of-hospital cardiac arrest (OHCA) and improve upon each link in their chain of survival.
When they recognized that significant CPR pauses occurred while moving patients in unresolved arrests to an ambulance, a protocol change was made directing providers to remain on scene while attempting resuscitation, rather than initiating immediate transport to a hospital. In order to further enhance CPR quality and promote EMS provider safety if a cardiac arrest patient was transported, LFR implemented use of the LUCAS mechanical CPR device.
And, after reviewing the most compelling cardiac research and recognizing that survival from shockable cardiac arrest was strongly correlated with cardiac cath lab intervention and the use of therapeutic hypothermia in the appropriate patient population, LFR leadership met with cardiology groups serving Lincoln, Neb., and all agreed that witnessed v fib/v tach cardiac arrest is a survivable disease and that variability and inconsistency in care leads to suboptimal outcomes.
The group identified cases in which patients survived prolonged cardiac arrest resuscitations when experiencing recurrent or refractory v fib and noted that the introduction of high-performance CPR and the LUCAS device led to field reports of cardiac arrest cases in which patients were breathing, blinking and moving.
A simple protocol of prehospital cardiac catheterization laboratory activation for any adult with witnessed, shockable cardiac arrest regardless of whether or not return of spontaneous circulation (ROSC) occurred was developed and LFR paramedics began to activate the cardiac catheterization lab in the same manner as they activated it for a STEMI patient and their results have been dramatic.
The Utstein survival for the 16-month period that preceded the protocol change was 23.8%. But the Utstein survival for the 29-month period after the protocol change is an amazing 59.2% thanks to the protocol change. During this period, 49 patients suffered a witnessed, shockable cardiac arrest. Of those 49 patients, 27 had a sustained ROSC prior to hospital arrival. Of those patients with sustained ROSC, 25 of the 27 patients (92.6%) survived to hospital discharge.
In Progressive System-wide Collaboration: Alameda County (Calif.) EMS coordinates with clinical stakeholders to improve cardiac arrest survival, progressive Alameda County (CA) EMS Medical director Karl A. Sporer, MD and Michael J Jacobs, EMT-P detail how the implementation of a comprehensive countywide EMS resuscitation program, implemented to close cooperation with the county’s hospital facilities, had dramatically improved care and successful cardiac arrest resuscitations.
Alameda County (ALCO) EMS has made a number of sequential changes over the last decade to improve OHCA care modeled after that of the decade-old and nationally recognized Take Heart America program and recommended evidence-driven treatment strategies, techniques and devices consistent with the AHA Guidelines.
Prior to 2012, mechanical CPR devices were available on just 10% of ALS first responder engines. But in 2012, all first responder paramedic engines were equipped with a LUCAS mechanical CPR device.
The multiple strategies for OHCA implemented resulted in a significant increase in ROSC (from 29% to 34%) and a 76% relative increase in those patients surviving with good neurologic outcome. The subgroup that received mechanical CPR and hospital hypothermia had the greatest improvement with a survival rate of 24%.
In 2016, shortly after the release of the 2015 AHA Guidelines, the topic of extracorporeal CPR (ECPR) using an extracorporeal membrane oxygenation (ECMO) device for patients experiencing refractory cardiopulmonary arrest (CPA) including OHCA was presented by EMS leadership. The case of a 15-year-old male that was a witnessed OHCA prompted the Alameda leadership team to explore the early use of ECMO in their system.
The only ECMO-capable hospital in the county at the time was the local Children’s Hospital and ECMO wasn’t considered for adult resuscitation, especially for use in refractory OHCA.
Alameda County leadership decided to explore its use more often in cardiac arrest cases and, in the fourth quarter of 2016, only a few months after first discussion with ALCO’s SRC/CARC stakeholders regarding the concept of using mechanical CPR as a bridge to ECMO, one center had their first opportunity to utilize the ECMO option and they did with amazing success!
Oakland Fire Department and Paramedics Plus took a 52-year-old male with a STEMI to Highland Hospital. The patient went into cardiac arrest in the ED and was placed on the hospital’s LUCAS mechanical chest compression device as resuscitative efforts were carried out.
At the time of the case, Highland Hospital didn’t have the capability to perform ECMO, so they contacted the University of California, San Francisco (UCSF), and the university agreed to dispatch their ECMO team to initiate ECMO care and transfer the patient to UCSF. The patient had his cardiac and cerebral perfusion maintained via a LUCAS device for several hours in the catheterization lab while waiting for the ECMO team to arrive.
After ECMO establishment, the patient was transferred to UCSF via ambulance, where he remained on ECMO for seven days with the intention of continued multisystem support. After a week on ECMO and his cardiac condition corrected, the patient was discharged presented with good cognitive return in memory, comprehension and social interaction.
Even though this case may be perceived as an outlier and an exception to the rule, it strongly suggests that it a progressive EMS system and fearless scientific community working together on behalf of the patient can achieve the unexpected, particularly with prolonged care with mechanical compressions administered and the application of ECMO.
In Rialto’s Resuscitation Toolkit: Seven survivability tools lead to dramatic improvements in cardiac arrest outcomes, Rialto (CA) Fire Chief Sean Grayson; EMS coordinator Joe Powell; and EMS quality improvement coordinator Kevin Dearden detail RFD’s amazing approach to resuscitation that is producing dramatic results and a significant improvement of ROSC and patient survival; 71% survival rate from SCA (Utstein). This innovate team of EMS leaders studied their system and realized from their outcome-based data that they needed to unlearn several things about cardiac arrest.
Their dramatic improvement in resuscitations are predicated on the following seven seven components of cardiac survivability, referred to as the RFD cardiac survivability tools:
- Continuous uninterrupted compressions utilizing an automated CPR device;
- Apneic oxygenation;
- Use of an impedance threshold device (ITD);
- Heads-up CPR;
- Delaying defibrillation for a certain subset of patient presentations;
- Expanded utilization of waveform capnography; and
- Deprioritizing epinephrine in the ordering of interventions.
When applying the RFD cardiac survivability tools to cardiac arrest patients in Rialto, they realized a 60% return of spontaneous circulation (ROSC) for all non-traumatic adult arrests; not just the very small number of patients that fit into the Utstein measurement, but all patients in cardiac arrest.
One of the most important lessons learned by RFD has been that “nothing trumps compressions, nothing! Not ALS or BLS, airway or venous access, defibrillation or definitive medical care; nothing should interrupt compressions. Uninterrupted compressions have been shown to be one of the key components to saving lives, so everything else should be support for those compressions.
When evaluating their use of their AutoPulse devices RFD had a Eureka moment, discovering that they had been using the AutoPulse in the same fashion they had previously used manual CPR, with too many pauses in compressions.
They changed their protocol to initiate and maintain continuous, uninterrupted compressions as soon as possible after patient contact, effectively maintaining a 100% compression fraction rate within the first 30 seconds of the resuscitation. RFD crews now initiate manual CPR, transition to the AutoPulse device within 30 seconds and then never turn off the device; not for intubation, defibrillation, rhythm checks or pulse checks.
Dr. Joe Holley writes about the success of Collierville Fire and Rescue (CFR) in increasing is resuscitations after implementing the ResQCPR System in their operation in Increased Cardiac Output & Cerebral Blood Flow = Increase Saves: New technology dramatically improves EMS system’s survival stats
Immediately after beginning use CFR, had seven neurologically-intact saves out of the first eight cardiac arrests managed (with the non-survivor dying as a result of serious traumatic head injury).
Prior to adopting the ResQCPR system, just 7% of patients where ROSC was achieved were discharged with normal neurological outcomes. However, after ResQCPR (the combined use of the ResQPUMP Active Compression Decompression CPR Device, and the ResQPOD Impedance Threshold Device) was implemented, the number of neurologically intact patients went up to an amazing 47%.”
In ECMO on the Streets of Paris: How SAMU responds and performs advanced ECMO care on the scene, Lionel Lamhaut, MD and his co-authors show the dramatic results experienced in Paris France through the deployment of a mobile ECMO team on selected cardiac arrests.
When the first disappointing results of in hospital ECPR for OHCA were published (4% of survival in patients presenting refractory OHCA being brought to the hospital for ECPR implementation), the main reason found for these poor resuscitation results was the prolonged low flow period (time between initiation of cardiac massage and ECPR pump flow).
So SAMU developed a mobile ECMO team to deliver ECPR to patients on the scene of the cardiac arrest in order to start implementation much earlier, immediately after the first 20 to 30 minutes of CPR.
Since implementing their Mobile ECMO team, Paris SAMU increased its survival rate from 8 to 29% with acceptable neurological status (CPC 1 and 2).
In ECMO for Massive Pulmonary Embolism: A Personal Experience, Joseph Ornato, MD, a cardiologist, EMS Medical Director for the Richmond Ambulance Authority and a JEMS Editorial Board Member tells his personal story of how Extracorporeal Membrane Oxygenation (ECMO), a resuscitation technique he has championed for use in emergency departments, saved his own life when he suffered a pulmonary embolism in his home in a suburb of Richmond.
In The Capnography Factor, Dr. Ray Fowler uses survey results from 31 medical directors from the U.S. Metropolitan Municipalities EMS Medical Directors Consortium (the “Eagles” Coalition) discusses the important role of EtCO2 in Termination of Resuscitation (TOR) but presents several cautions about why EtCO2 may not always be a final determinant of when to terminate resuscitations.
The JEMS/Pennwell staff and our authors wish you a safe holiday season and hope that you benefit from this cutting-edge editorial content backed up by real data, case histories; current, extensive footnote and, most importantly, examples of how EMS systems are doubling or tripling their resuscitation saves in the field.