The Arizona Cardiac Arrest Center Consortium

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The Arizona Cardiac Arrest Center Consortium
Ben Bobrow, MD Assistant Professor, Department
of Emergency Medicine, Mayo Clinic Hospital,
Medical Director, Bureau of EMS Trauma System
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PRESENTER DISCLOSURE INFORMATION

• Ben Bobrow, MD
• Disclosure Information
• The following relationships exist related to
  this presentation
• None

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ArizonaCardiac Arrest Center Consortium

• Purpose
• To further improve survival from out-of-hospital
  cardiac arrest in Arizona through implementing
  standardized, guideline-based post resuscitation
  care in our state

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Discussion Goals

• Review current updates in resuscitation including
  importance of high quality, minimally interrupted
  CPR
• Confer the role of therapeutic hypothermia in
  post-cardiac arrest care
• Describe the Arizona Cardiac Arrest Center model
  of care

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Approximately 5,000 SCA/YR in AZ
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Out of Hospital Cardiac Arrest A Common Disease

• 1000 Americans will suffer OHCA today
• 1000 Americans will suffer OHCA tomorrow
• 25 will suffer OHCA during this talk
• High morbidity and mortality
• 47 never make it to the hospital

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Where Can EMS Make A Difference in Outcomes?

• Cancer
• Pneumonia
• AIDS
• Kidney Disease
• Diabetes
• Alzheimers
• NOT YET

• Cardiac Arrest
• Major Trauma
• ST-Elevation MI
• Acute Stroke
• PROVEN!

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Different Approach to OHCA

• OHCA is a major public health problem
• We SHOULD maximize our resources and
  collaborations with the goal of improving
  survival
• We NEED to have a REALISTIC idea of what happens
  in the field where the battle is fought
• Emergency medicine leaders MUST guide the
  community on how to bridge the gap between
  current knowledge and practice

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Model for OHCA Collaboration

• AHA
• Municipal FDsPublic HealthPrivate Ambulance
  Local HospitalsProfessional Societies
• Private IndustryUniversity Research
• Public Safety Officers
• Public

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71 SHARE Participants
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OHCA Survival in Arizona
With so few survivors, we felt compelled to make
modifications to protocol based upon current
evidence and track the results closely
50 40 30 20 10 0

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Arizona 2004
Bobrow B et al. Circulation. 2006 114II 350.
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OHCA Survival
50 40 30 20 10 0
Neurologically normal survival ()
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3
2
1
1
Chicago 87
Ontario 89
Arizona 04
Seattle 01
LA 00
Eckstein M et al. Annals of Emerg
Med. 200545 Issue 5504-509 Rea T et al.
Circulation. 20031072780-2785
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Many Reasons for Low OHCASurvival

• Poor public knowledge of cardiac arrest
• Delayed time to first defibrillation
• Low rates of bystander CPR
• Inconsistent quality of professional CPR
• Inconsistent post cardiac arrest care
• WE havent adequately implemented what we already
  know

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Standard CPR (with breaths) vs. CC alone
Blood pressure
Time
chest compression
Berg et al, 2001
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Standard CPR (with breaths) vs. CC alone
Blood pressure
Time
chest compression
Berg et al, 2001
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Hyperventilation during CPR
Aufderheide et al. Circulation 2004 1091960-5
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Three-Phase Model of VF
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Myocardial ATP
0
0
2
4
6
8
10
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18
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Arrest Time (min)
Weisfeldt ML, Becker LB. JAMA 2002 2883035-8
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Cardiocerebral Resuscitation (CCR)
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
200 chest compressions
200 chest compressions
200 chest compressions
200 chest compressions
CC Only
Analysis
Analysis
Analysis
BVM or Passive Insufflation 100 FIO2 Begin IV
Resume Standard ACLS Consider Endotracheal
Intubation
Administer 1 mg IV Epinephrine

• If adequate bystander chest compressions are
  provided, EMS providers
• perform immediate rhythm analysis

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CCR vs. 2005 AHA Guidelines

• CCC-CPR for bystanders
• ACLS Passive O2/BVM
• (protocol delayed ETT)
• 200 CC prior to shock
• 200 CC immediately post shock
• Early epinephrine IO/IV
• Hypothermia for all comatose

• 302 CC to V
• (Bystander Hands-Only CPR)
• ACLS 8-10 breaths/min
• (timing of ETT by provider)
• Optional 5 cycles of 302 prior
• 5 cycles of 302 post shock
• Epinephrine second cycle
• Hypothermia for VF/VT comatose

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Hypothesis

• OHCA victims in Arizona receiving Cardiocerebral
  Resuscitation would have higher survival rates
  than victims receiving routine Advanced Life
  Support

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Methods Data Collection and Training

• Utstein style database
• October 2004 to August 2007
• 11 of 61 (18) elected to change to CCR
• Train-the-trainer program
• January 2005 to April 2007
• 3,000 EMT (B) and (P) trained

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Enrollment

Total cardiac arrests n 3,329
171 excluded (age lt18 yrs)
3,158 adult

• 874 excluded
• 673 non-cardiac
• 139 EMS witnessed
• 62 missing outcome

2,284 arrests of cardiac etiology
1,686 Routine ALS
598 CCR
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ResultsCharacteristics of OHCA Victims

• Characteristic CCR (n598) ALS
  (n1,686)
• Mean age, years (SD) 66.1 (15.5) 67.9 (15.0)
• Males, (n) 68.7 (411) 65.1 (1,098)
• Home location, (n) 76.1 (455) 70.8 (1,194)
• Bystander CPR performed, (n) 39.3 (235) 39.3
  (663)
• Witnessed, (n) 45.2 (270) 44.1 (744)
• Ventricular fibrillation, (n) 32.6 (195) 30.3
  (510)
• EMS dispatch to arrival time interval, mean
  minutes (SD) 5.2 (2.2) 5.6 (3.2)
• Witnessed collapse to defibrillation time
  interval, mean minutes (SD) 13.7 (6.9) 13.3
  (7.6)

SD Standard deviation plt0.05 plt0.01
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ResultsSurvival from Out of Hospital Cardiac
Arrest
(36/128)
CCR
30 25 20 15 10 5 0
ALS
28.1
Survival to Hospital Discharge ()
(38/348)
(55/598)
10.9
9.2
(61/1686)
3.6
All cardiac arrests
Witnessed with VF
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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
200 chest compressions
200 chest compressions
200 chest compressions
200 chest compressions
CCC Only
Analysis
Analysis
Analysis
BVM or Passive Insufflation 15L NRB Begin IV
Resume Standard ACLS Consider Endotracheal
Intubation
Administer 1 mg IV Epinephrine

• If adequate bystander chest compressions are
  provided, EMS providers perform immediate rhythm
  analysis

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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
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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
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Conclusion

• Widespread implementation of Cardiocerebral
  Resuscitation resulted in a significant
  improvement in adult OHCA survival compared with
  routine Advanced Life Support care over the same
  time period in Arizona

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• "Statewide Survival From Out-of-Hospital Cardiac
  Arrest Improves with Widespread Implementation of
  Cardiocerebral Resuscitation"
• American Heart Association
• Best Resuscitation Abstract
• Scientific Sessions 2007

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Important Questions

• Perhaps witnessed VF but what about unwitnessed
  VF, asystole and PEA?
• What part of the CCR protocol is most critical?
• What is the optimal training method and
  retraining frequency?
• Will CCC-CPR truly improve bystander CPR rates?

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Sarver Heart Center SHARE Program Initiative for
Excellence in CPR

• Cardiocerebral Resuscitation
• Be A Lifesaver (Lay individuals)
• New ACLS Algorithm (Dispatchers,
  Firefighter/Paramedics and Medical Personnel)
• Post Resuscitation Care (In-Hospital)

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HOW DO WE FURTHER IMPROVE SURVIVAL?
Therapeutic Hypothermia
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For 50 years we have been sitting here.
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Reperfusion Injury

• Reperfusion injury is defined as damage observed
  after restoration of blood flow to ischemic
  tissues
• There are three potential treatment modalities to
  counteract the untoward effects of reperfusion
• Increased ICU care and length of stay
• Antioxidants
• Hypothermia induction

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Clinical Hypothermia Mechanism of Action

• There are three distinct stages of cerebral
  injury after hypoxic insult
• Early
• Intermediate
• Late
• Therapeutic hypothermia is considered to be
  neuroprotective by acting at each of the three
  stages of injury

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Mechanism of Hypothermia

• Decrease in cerebral metabolism
• 6 reduction for every 10C drop in temperature
• Suppression of reperfusion injury
• Decreased free radical production
• Reduction in excitatory neurotransmitters
• Suppression of Ca2 mediated cell death
• Anti-inflammatory effects
• Nolan et al. (2003) Circulation
• Froehler and Geocadin. (2007) J of Neuro Sci

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Proof of Theory Studies
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Mild Therapeutic Hypothermia to Improve the
Neurologic Outcome After Cardiac Arrest (HACA)

• Patients with witnessed cardiac arrest from VF or
  pulseless VT, 18-75 years of age, estimated 5-15
  minutes to attempted resuscitation, and less than
  60 minutes from collapse to restoration of
  spontaneous circulation
• 275 patients of 3,551 cardiac arrests studied
• 137 patients received hypothermia

Dr. Fritz Sterz, Vienna, Austria, and The
Hypothermia After Cardiac Arrest Study Group, N
Engl J Med 2002 346549-556
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Hypothermia in Cardiac ArrestEuropean experience

• Normothermia pts had target temperature of 37o C
• Pts assigned to hypothermia had target temp of
  32-34o C by use of an air cooled tent and
  mattress
• hypothermia was maintained for 24 hrs followed by
  passive rewarming over 8 hrs

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Bladder Temperature Course
Normothermia ( n 124)
Hypothermia ( n 123)
Dr. Fritz Sterz, Vienna, Austria and The
Hypothermia After Cardiac Arrest Study
Group, N Engl J Med 2002 346549-556
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Hypothermia in Cardiac ArrestEuropean experience

• Outcomes (at 6 mo)
• 55 of the HT group had a favorable outcome
  compared to 39 in the NT group, p 0.009
• mortality was 41 in the HT group compared to 55
  in the NT group,
• p 0.02

The HACA Study Group, NEJM2002346549-56
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Hypothermia in Cardiac Arrestthe Melbourne
experience

• NT pts had target temperature of 37o C
• HT pts had target temp of 33oC by extensive
  application of ice packs
• 43 pts were randomized to HT, 34 to NT
• Hypothermia was maintained for 12 hours then were
  actively rewarmed at 18 hours for the next 6 hours

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Hypothermia in Cardiac Arrestthe Melbourne
experience

• Outcomes
• 49 of the HT group had a good outcome compared
  with 26 in the NT group, (plt0.05)
• mortality was 51 in the HT group and 68 in the
  NT group, (pNS)

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HACA Complications(all N.S. between groups)

• NT Hypothermia
• Bleeding 19 26
• Pneumonia 29 37
• Sepsis 7 13
• Pulmonary Edema 4 7
• Renal Failure / HD 10 / 4 10 / 4
• Seizure 8 7
• Serious Arrhythmia 32 36
• Pancreatitis 1 1

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Compare ICU Strategies (Gropper, Anesth Analg
2004 99566)

• Treatment NNT (mortality)
• Early Goal-directed therapy 7
• Low-dose steroid 10
• ARDSnet low TV ventilation 12
• Activated protein C 17
• Intensive glycemic control 28
• Hypothermia 6.1-7.0

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Conclusions

• In patients who have been successfully
  resuscitated after cardiac arrest due to
  ventricular fibrillation, therapeutic mild
  hypothermia increased the rate of a favorable
  neurologic outcome and reduced mortality.
• -from The Hypothermia After Cardiac Arrest Study
  Group
• treatment with moderate hypothermia appears to
  improve outcomes in patients with coma after
  resuscitation from out-of-hospital cardiac
  arrest.
• -from SA Bernard et al

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Recommendations

• Unconscious adult patients with return of
  spontaneous circulation (ROSC) after out-of
  hospital cardiac arrest should be cooled to 32C
  to 34C (89.6F to 93.2F) 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

American Heart Association 2005 Guidelines
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• Endorsed by the International Liaison Committee
  on Resuscitation
• Nolan JP, et al. An advisory statement by the
  Advanced Life Support Task Force of the
  International Liaison Committee on Resuscitation.
  Resuscitation. 2003 57231-235

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Post Resuscitation Care in Arizona

• A 2006 survey of 61 acute care hospitals in
  Arizona revealed that only 5 hospitals had done
  TH and only 2 hospitals had TH protocols.
• None of the patients in the SHARE database
  received TH.

Snyder Q, et al. Western Journal of Emergency
Medicine 2008 Vol. 9, No. 1, Article 26
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Optimal treatment during reperfusion
PCI/thrombolysis (if indicated) Initiate
cooling Optimalisation of hemodynamics
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38C
Brain Injury
37C
36C
Positive Inotropy, Increased SV, Decreased
HR, Heart Protection
35C
32ºC - 34ºC
34C
Brain Protection
33C
32C
31C
30C
Dysrhythmia / Irritability
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Practical Approach to TH

• Induction Phase
• Cold IV saline is best
• NG Lavage may help
• Cold packs placed in groin and axilla
• Maintenance Phase
• Blanket is cheap and effective
• Intravascular catheter
• External cooling pads
• Rewarming Phase
• Internal or external or warming blankets
• 0.25 0.5 degrees C per hour

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Alsius IVTM
Vein Placement options Femoral Subclavian
Internal jugular
Alsius catheters also provide triple-lumen
central venous access.
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Medivance Arctic Sun
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The LRS ThermoSuit System
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Treatment of Comatose Survivors of
Out-Of-Hospital Cardiac Arrest with Induced
Hypothermia (Bernard) Cooling Device
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The Shivers !

• Normal people will shiver and not cool more than
  1 C
• We can abate that with benzos or propofol
• Last resort is paralysis, but watch for seizures
• Cold IVF gets people cold faster, but you will
  need more than fluids to maintain.

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Post Resuscitation CareOslo, Norway Experience

• Found that only 34 of patients initially
  resuscitated and delivered to the ED survived to
  discharge
• They Formalized an approach to post-resuscitation
  care
• Therapeutic Hypothermia
• PCI when indicated
• Ventilation Control
• Glucose Control
• Hemodynamic Control

Sunde K, Steen PA and Associates
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Aggressive Post Resuscitation Care Saves Lives
60 50 40 30 20 10
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p lt 0.05
Survival
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Before
After
Pytte M, Jensen LP, Smedsrud C, Jacobsen D,
Mangschau A, Sunde K. Oslo, Norway
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Brian Duffield, Finishing the 3 mile Rough Water
Swim in the Pacific Ocean on Sept 9, 2007. 16
months after being resuscitated
from out-of-hospital cardiac arrest and then
receiving therapeutic hypothermia and early
cath/PCI.
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What could EMS offer the pt?

• 22 pts post ROSC who remained comatose
• 30ml/kg of ice-cold saline given via peripheral
  IV or femoral central line over 30 min after
  patient evaluated and paralyzed
• Decreased core temp from 35.5 to 33.8C

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Bernard SA, et al. Resuscitation 2003 569-13
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Prehospital CoolingHypothermia post-cardiac
arrest

• Use of ice cold IV LR in pre-hospital for
  comatose pts post arrest
• Pts given 30cc/Kg at rate of 100 ml/min
• Air ambulance with 25 min infusion
• Pts reached target temp of 34 C with arrival to
  ED
• Resuscitation. 200462299-302

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Formal Designation of Cardiac Arrest Centers

• Protocol and technique for TH
• 24/7 PCI capability and protocol for eval
• Protocol for Termination of Care
• Protocol for organ procurement
• Collect 1 page data form
• Participation in the CAC Consortium

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HIPAA Compliant  

• Pursuant to 45 CFR 164.512(b) of the HIPAA
  Privacy Rule, covered entities may disclose,
  without individual authorization, protected
  health information to public health authorities
  authorized by law to collect or receive such
  information
• The Bureau of EMS Trauma System has authority
  to collect and receive protected health
  information and related records for public health
  purposes pursuant to A.R.S. Title 36, Chapter
  21.1 In January 2005, the SHARE program was
  designated a public health program by the Arizona
  Department of Health Services.

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Implementation Strategy

• Handout to each interested
• Cardiac Arrest Center Consortium member

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Sample protocols http//www.med.upenn.edu/resuscit
ation/Hypothermia.htm
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Summary

• Hypothermia is part of a total care package
• A protocol for therapeutic hypothermia and PCI is
  necessary to assure efficient treatment and
  optimal results.
• TH should be initiated ASAP after ROSC, but
  appears successful even if delayed 4-6 hours.
• System-wide implementation of standardized post
  resuscitation care is feasible and will save
  lives.

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Cardiac Arrest CentersArizona
Already 15 Centers
gt 200 patients per year statewide will benefit
from this system enhancement
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Thank you

• Our goal is for Arizonans to have the highest
  survival rate in the world for cardiac arrest
  victims.
• www.azshare.gov