The History of Resuscitation An Insiders Look

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The History of Resuscitation(An Insiders Look)

• Presented by
• Mike Helbock, M.I.C.P., NREMT-P, SEI
• MSO King County Medic One
• Manager - EMS Training and Education
• Seattle/King County
• Division of Emergency Medical Services

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A special thanks to Mickey Eisenberg, MD, PhD at
the University of Washington School of Medicine
and Medical Program Director for Seattle/King
Emergency Medical Services for his help and
guidance during my research Mike Helbock
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In the beginning
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AIRWAY AIRWAY AIRWAY
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Based on Science or
Trial and error
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The bellows effect early airway devices
The early days
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Good air in
Bad air out!
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Now its official!
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From an official lifeguard manual!
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The beginning of modern day mouth to
nose/mouth Circa 1950
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Peter Safar
Rescue Breathing, 1958
James Elam
Introduction to Modern Day Respiratory and
Cardiac Resuscitation, 1957-61
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External Cardiac Massage Moves Forward! Circa
1960
Kouwenhoven, Knickerbocker Jude
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Mouth to Mouth Meets Electricity!
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The first human to be defibrillated occurred in
1947 by Dr. Claude Beck
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New portable ECG and Defibrillator Circa 1960
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Bringing it to the Field The Birth of Paramedics
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First Medic Unit in the world circa 1966
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Belfast, Ireland
First Medic Unit in the worldJanuary 1, 1966
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The birth of Medic One
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First Paramedic Programs U.S.

• Miami
• Seattle
• Columbus, Ohio
• Los Angeles
• Portland

Circa 1969
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Leonard Cobb, MD The father of the
Seattle Medic One Program. Circa 1969
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Seattles First Medic Unit Moby Pig
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First field 12 lead Circa 1969
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Major Developments Since the 1970s

• Defibrillation by EMTs and First Responders
• Automated external defibrillators (AEDs)
• Public access defibrillation
• Dispatcher assisted telephone CPR

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The history continues
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Weve come a long way
From this
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To this
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Sowhats on the New to Do list

• New thoughts. CPR compression/numbers
• Quality of CPR (DVD-R)
• New Studies
• Emesis Study/Observation
• DART Studycompressions only
• Hypothermia in Resuscitation
• Adjuncts
• Geezer Squeezer (ASPIRE)
• OTC AEDs
• Resuscitation Outcome Consortium

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New thoughts on the numbers
One minute of CPR between shocks may not be
enough
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A Little Background
Each of the links in the chain of survival are
important for resuscitation.
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Background
Though the emphasis has been placed on early and
frequent defibrillation.
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Background
We hoped the reduction in time to defibrillation
would produce better survival.
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40
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Survival
20
10
0
1977-81
1982-85
1986-89
1990-93
1994-97
1998-2001
25 years
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Background
What actually happened (shown in the red bars)
we did not achieve the survival improvement we
had hoped for.
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40
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Survival
20
10
0
1977-81
1982-85
1994-97
1998-2001
1986-89
1990-93
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Background
So we reviewed the AHA protocol

• Determination VF (how long does this take)
• Stacked shocks (why)
• Pulse check, before and after shocks (why)
• 1 minute of CPR and re-analyze(is it enough)

AND
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So We Looked Harder..
We looked more closely at the relationship
between CPR and defibrillation from a
physiological standpoint.
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The Shock 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.
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SoOut 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

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In With the New!
So we implemented a single shock start CPR
algorithm in January 2005.

• Eliminated stacked shocks

Eliminated pulse checks after a shock
Extended period of CPR following shock from 1 to
2 minutes
The goal was to increase CPR especially during
the period immediately following the shock.
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What happened since the change?

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

2. Duration of CPR increased from 50
seconds to 95 seconds.
3. Survival to hospital discharge went from X to
X____?
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Summary
More hands on
Less shocks than before
More focus on Quality CPR
New methods of resuscitation - cooling -
ITD - mechanical devices
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Which brings us to the question
CAN WE DO EVEN BETTER?
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New Age CPR A Return to Quality
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New CPR Guidelines
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CPR First Study
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CPR Questions

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

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New CPR Guidelines
ADULTS 302
1 or 2 person CPR WITHOUT intubation
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New CPR Guidelines
ADULTS 302
1 or 2 person CPR WITHOUT intubation
Medics arrive and intubate
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New CPR Guidelines
ADULTS 302
1 or 2 person CPR WITHOUT intubation
Continuous compressions with 8-10 ventilations
per minute. (1 breath/6-8 sec.)
Medics arrive and intubate
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New CPR Guidelines
INFANTS/ CHILDREN 152
2 person CPR WITHOUT intubation (HCP)
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New CPR Guidelines
INFANTS/ CHILDREN 152
2 person CPR WITHOUT intubation (HCP)
Medics arrive and intubate
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New CPR Guidelines
INFANTS/ CHILDREN 152
2 person CPR WITHOUT intubation (HCP)
Continuous compressions with 8-10 ventilations
per minute. (1 breath/6-8 sec.)
Medics arrive and intubate
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Quality CPR!
D Depth of compression V Ventilation (chest
rise) D Decompression (recoil) R Rate of
compression
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CPRFocus on Quality

• Depth of compressions

Depth of 1 1/22 inches (or more in larger
people). Minimize interruptions in chest
compressions. Rotate compressors every 23
minutes to minimize fatigue.
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CPRon Quality
302 prior to intubation. 810 ventilations per
minute when intubated. (1 breath/6-8
sec) Inspiration phase of no more than 1 second.

• Depth of compressions

Ventilations
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CPRon Quality
Complete chest recoil after each
compression. REQUIRED!
Depth of compressions
Ventilations
Decompression
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CPRon Quality
Push Hard / Push Fast (100/min)
Depth of compressions
Ventilations
Decompression
Rate of compression
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Sowhat are we doing about it?

• Research, Research, Research..
• Shock earlyshock oftenshock 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!

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The Studies
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The Pukers
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Emesis Study

• Observation Study
• Help manage/understand airway issues
• Did theyor didnt they?
• If they didoutcome/discharge?
• If they didntoutcome/discharge?

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D.A.R.T.
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D.A.R.T. Study

• Dispatcher Assisted Resuscitation Trial
• Seattle/King County and London, England
• Telephone assisted CPR
• Green card tells all!
• If someone knows CPR Normal way, 302
• If no knowledge of CPR (and they agree)
• Dispatcher opens the Green card 50/50 chance for
  Chest Compression only

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The Deep Freeze
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Hypothermia Study
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Change in Focus

• ROSC is not good enough
• Advances in cardiac resuscitation
• Morbidity/mortality
• Neurologic injury
• Focus on Brain Protection
• We want productive survival not just a
  beating heart!

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Cooling

• Induction of hypothermia
• (in the field). (32-34 degrees C)

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Advanced Care

• Randomized trials of in hospital cooling
• Neuro-Intact Survival
• Standard care Cooled
• Australia (n77) 26 49
• Europe (n243) 39 55

Bernard SA et al. N Engl J Med Abella BS et al.
Circulation
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Therapeutic Hypothermia

• First introduced in the 1950s
• 1958 moderate hypothermia (28-32 C) promising
  results in cardiac arrest

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• The use of hypothermia re-discovered by group at
  Pittsburgh (1987).
• Use of mild hypothermia was found to be
  beneficial in dog models of cardiac arrest
• Hypothermia needs to be started as soon as
  possible, even delay for a few hours still
  beneficial

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Seattle Cooling Study

• 2 liters of normal saline
• Kept at 4 C
• Infused after ROSC

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Conclusions

• Mild hypothermia (32-34 C) is a promising
  treatment for cardiac arrest patients
• All hospitalized cardiac arrest patients should
  be cooled at least with cooling blankets and
  muscle relaxants
• IV cooling appears to be safe, rapid, and
  effective.

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The Geezer Squeezer
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The ASPIRE Study

• A 5-Center International Trial of a new FDA
  approved CPR device. The AutoPulse ASsisted
  Prehospital International REsuscitation Trial
  began June 1, 2004.

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AutoPulse Resuscitation System
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LifeBand Chest Compression Assembly

• Single-patient use
• Automatically adjusts to patient size and shape
• Applies only a fraction of the pressure compared
  to manual compressions

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Buy it at the Drug Store
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OTC Home Defib Units

• FDA removed the 510K requirement for prescription
• Drug Store.com
• Costco
• Viewed as personal safety devices

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Need to catch your breath?
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Hyperventilation- induced hypotension Study

• Milwaukee, Wisconsin
• Pre-hospital providers where observed to
  routinely over-ventilate patients during
  cardiac arrest.
• Pigs were used in the study
• Conclusion marked reduction in coronary
  perfusion and subsequent reduction in patient
  survival rates were seen with hyperventilation!!!

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The ROC
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Welcome to the ROC
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R.O.C.

• Resuscitation Outcome Consortia
• Federally Funded Data Collection Study
• Study Specific EMS Interventions
• Seattle - selected coordination site
• Pittsburgh, Pa.
• Birmingham, Al.
• San Diego, Ca.
• Portland, Or.
• Ottawa

• Toronto
• Milwaukee, Wi
• Dallas, Tx.
• Iowa

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ROC Sites
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ROC Sponsors

• National Institutes of Health
• Canadian Institutes of Health Research
• Defense Research Development Canada
• American Heart Association
• Heart Stroke - Canada

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What is the ROC?

• 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.

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The Cardiac Arm
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Purpose of the Study
To determine outcomes in cardiac arrest when
comparing
Difference between CPR with the ITD and CPR with
a sham valve.
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Difference between analyze early and analyze late
protocols.
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Analyze Early/Analyze Late

• 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?

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Analyze Early/Analyze Late

• 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

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Using the ITD Valve
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ITD Valve

• 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.

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Purpose of an ITD Valve

• Prevents air flow into chest during recoil.

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

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

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ITD Valve

• Can be used with
• Bag-valve-mask
• Endotracheal tube (ETT)

ITD Valve with head strap
ITD Valve without head strap
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and the quest continues
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Acknowledgements

• Michele Olsufka, RN
• Dr. Cobb
• Dr. Copass
• Dr. Mickey Eisenberg
• Dr. Tom Rea
• David Carlbom, MD
• Will Longstreth, MD
• Steve Deem, MD
• Peter Kudenchuk, MD
• Charles Maynard, PhD
• Medic One Foundation

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Mike Helbock
206-423-4674
Mike.helbock_at_metrokc.gov