1. Time, ATP, CPR and Seattle EMS Honolulu 2014 ACLS Update Joseph Lewis, M.D. Medical Director, HESD Diplomat American Board of Emergency Medicine Former Fellow, American College of Emergency Physicians

2. Overall Cardiac arrest survival in America is estimated at 5% Seattle, Washington EMS overall survival is over 54% That's their discharge alive from the hospital rate! Looking around the country you see Seattle 54% Rochester 40%, and several other cities until you get to us. Honolulu 9%

3. This year I travelled to Seattle, Washington because their EMS system has the best cardiac survival rate in the country. I went there to learn what do they do differently in their community, in their training and to see their protocols. I listened to two days worth of both science and watched hands CPR presentations.

4. 4 I was in the presence of the men and women who helped write many of the American Heart Associations ACLS, BCLS and Pediatric ACLS protocols. They helped write the guidelines used all over our nation and our world. I absorbed as much information as I could.

5. 5 And the my head started to explode

6. 6 This is how I felt.

7. 7 I had information overload. So I went and asked the Medics two questions. What is the main thing you remember about resuscitation science? How does all this science work in the field?

8. 8 The answer: If you understand ATP, everything makes sense. The question: "What's the most important thing you remember about all this cardiac science?"

9. 9 Imagine this newspaper headline! SCIENTIST DISCOVER ATP! The fuel for Cells! AP January, 2014 Scientists discovered ATP. A molecule which fuels cells.... Story continued on next page.

10. 10 ATP Story continued. Lack of ATP causes cells to die. Restoring ATP levels restores life to cells. The AHA has perfected a technique called CPR which can restore ATP levels in cells. Once ATP levels are restored the cells respond to the shock of life.

11. 11 This is an imaginary headline. But it contains some important facts. These facts apply directly to what we do!

12. The fuel that your cells run on is called ATP. Normal blood flow brings your cells the stuff they need to make ATP. In a cardiac arrest, blood flow stops and your cells stop making ATP, but cells don't stop using ATP until it's all gone. Your cells will die unless normal ATP levels are restored.

13. 13 The longer it is until blood flow is restored, the lower the chance of survival. ATP level drop 10% every minute, at four minutes shocks and drugs don't work. After 4 minutes only good CPR can restore ATP to the level where shocks and drugs work.

14. An important time cutoff is 4-5 minutes. The first phase of a cardiac arrest is called Electric Phase and it lasts for 4-5 minutes after the patient collapses.

15. 15 During this phase the heart cells don’t have enough ATP to respond to electricity and drugs. That's why it's called the electrical phase. Unfortunately even though you have lost only 40-50 percent of your ATP when this phase is over, greater then half of all survivals come from this phase. So any delay that moves you out of this phase drops your survival by more then half.

16. 2nd phase is circulatory phase: It is from 4 or 5 minutes to 10-12 minutes after collapse. 3rd phase is the metabolic phased: it is more then 10-12 minutes after collapse.

17. 17 During these phases ATP levels are to low for shocks or drugs to work without good CPR raising ATP levels first.

18. 18 This chart shows how ATP levels drop over 10 minutes. At the bottom it shows the phase.

19. 19 Let's Review Our cells run on ATP. When blood flow stops in a cardiac arrest, ATP production stops, but ATP consumption continues. ATP levels fall about 7-10% per minute. Survival falls 7-10% per minute.

20. 20 Let's Review continued After 4-5 minutes drugs and shocks don't work because ATP levels are to low. After 4-5 minutes only good CPR can save the patient.

21. 21 The next slides are some quotes from the Medics I spoke to in Seattle.

22. "The bottom line is you gotta get there before they run out of ATP. Or else you gotta work really hard, doing really good CPR, to help them make ATP really fast, cause you gotta get a pulse back fast, to give them a chance to survive. Quotes from the Seattle Medics

23. 23 Quotes from the Seattle Medics "Time is ATP, ATP is survival" The more time it takes to get to the patient, the less ATP they have and the lower their chance of survival.

24. 24 Time and ATP If you understand ATP goes down with time. And you understand survival goes down with time. Then You understand the 2 of the 3 most important things. The 3rd thing is that CPR restores ATP.

25. 25 Okay that's the science part. Now my second question for their field personnel. How does all this work in the field? How do you apply the science?

26. 26 Their field personnel told me: "...we get to a code as soon as possible, make room at the scene to work, do the best CPR possible, start lines and intubate around CPR, only stop to shock and don't give up until we get a pulse or we are in asystole or agonal at least 20-30 minutes, usually longer"

27. 27 They said they sometimes run 30-40 minute codes, but most are much shorter. They said if you get there fast you get them back fast.

28. 28 "Most of what we do is about saving time or not wasting time, because time is the same thing as ATP and every minute is less ATP and your chances of getting them back alive go down." Quotes from the Medics in Seattle, Washington

29. 29 "The rest of what we do with good CPR is make ATP the most efficient way possible, so we get them back faster and they do better in the hospital."

30. 30 We don't move the patient because that wastes time and wasting time costs lives. Besides the American Heart Association says EMTs and Paramedics run codes just as good as the hospital, so what's the point? ( in moving the patient. )

31. 31 We might be better at CPR because we practice it, but mainly we are lucky because we have protocols that let us do our job for the patient in the field cause that's where the patient has the best chance of survival. And the American Heart Association agrees with us."

32. 32 Their field personnel said they run the codes until they get a pulse or pronounce. I asked why don't they don't transport to the hospital? They said they have learned they can run a code just as well as the ER can, but they have a better chance of success due to the time delay of driving to the ER decreases the patients chance of survival.

33. 33 I said "We get pulses back in the ER" That's when the Medics told me the ER can get back a pulse, but we have the best chance to get back a person.

34. 34 So I checked my AHA literature ER's can get a pulse back on a patient coded by EMS. But it's very rare. More importantly, the AHA statistics say the longer it takes to get them back, the lower their ultimate survival is and if they survive they have poor neurological outcomes.

35. 35 So the ER saves have more brain damage and lower survival rates. The Medics were right. The ER can get back a pulse, but Medics have the best chance to get back a person.

36. 36 That really struck me as a pivotal idea. Getting back a pulse is great, but getting back a person... that's the real goal. And to do that we need to focus on time and CPR.

37. Time dictates 1. What phase of cardiac resuscitation we are in. 2. How much ATP are left. 3. What treatments are likely to work. 4. And the chance of survival. The AHA and Seattle EMS are focused on time and good CPR because:

38. 38 The AHA and Seattle EMS are focused on time and good CPR because: Time Get there fast and the patient still has ATP so you can shock and give drugs Don't do stuff that wastes time

39. 39 The AHA and Seattle EMS are focused on time and good CPR because: If you can't get there at a time when the patient still has ATP, you have to make ATP doing good CPR Time

40. 40 Seattle EMS saves over 50% of their codes by focusing on early recognition, early CPR, early defibrillation, doing good CPR, minimizing ventilation, eliminating pauses, eliminating movement, and minimizing interruptions.

41. 41 Finally, while in Seattle I also listened to presentations from small EMS agencies from all over the state of Washington, as they described their efforts to duplicate Seattle's success. One true measure of a successful model or idea is reproducibility. Can we take ideas from here and apply them there and have them work.

42. 42 They all reported improvements in survival. They reported remarkable and steady improvements. One agency started at 5% and improved in one year to 15%. Another improved to 20% And yet another improved to 34%!

43. 43 What can we improve to?

44. 44 These are 8 the things our EMT's, Paramedics, MICT's and MECS need to do differently and are now officially HESD Policy. 1. Run all resuscitations in place until we have a pulse 2. Don’t move the patient, move the furniture. 3. Do good CPR focusing on compression and decompression. 4. Don’t stop CPR for ventilation and ventilate very little 6-10 per minute.

45. 45 These are the 8 things our EMT's, Paramedics, MICT's and MECS need to do differently and are now officially HESD Policy. 5. Interpose breaths with continuous compressions no stops for breaths. 6. Don’t pause CPR for intubation, IV and movement 7. Run all resuscitations in place until we have a pulse. 8. Focus on restoring circulation, raising ATP levels and doing ALS interventions without stopping CPR.

46. 46 Questions I thought you might ask?

47. 47 A change in policy requiring patients to be coded in place brings up at least two questions. When do we stop? You may consider stopping for adult patients when the patient meets the following: patients has been receiving optimal CPR in your presence and ALS for at least 20 minutes, patient has been in asystole for a minimum of 20 minutes and the patient has received good CPR and appropriate ALS drug interventions that full time. I encourage you to try longer such as 30 minutes. If the patient has electrical activity you should continue the resuscitation as long as there is electrical activity such as Vfib, pulseless bradycardia or PEA.

48. 48 What does this mean for the scene time limit? The limit is extended. This is the biggest emergency of your patients life and all studies show they are better off with you running their code right there. What does this mean for area coverage? It means dispatch makes adjustments, standbys and other movements. Realize that We tie up units for trauma patients more times then codes.

49. 49 AHA criterion for stopping resuscitation include + Hawaii State Adults 1.The arrest was unwitnessed by EMS or first responder 2.No bystander CPR 3.No return of spontaneous circulation after 3 full rounds of CPR and full ALS care* (Full ALS care means drugs and shocks) 4.No AED shocks 5. Asystole for at least 20 minutes (State of Hawaii criterion) Pediatric 1.AHA says no conclusive criterion established for terminating Pediatric arrests in the field, so after full attempt to resuscitate at the scene, transport to closest facility. 2.AHA states that EMS transport and ER Care is importsnt only as part of the grieving process for parents. 3.AHA recommends full ALS care at the scene until adult criterion fulfilled and then transport or communicate for pronouncement. We have adopted transport to nearest facility in Honolulu County

50. 50 How Do We Do the Best CPR Possible?

51. Compressions+ Decompression + Ventilation= CPR

52. Compression = flow to brain & body. Decompression = blood flow to heart. Recoil= Decompression

53. Compression achieves good blood flow after several compressions have built up some blood pressure to send blood to the brain and body. When you stop it falls back to zero and it takes several compressions to build it back up. Every 3 second pause means 16 seconds to recover the blood flow, which really means a 19 second pause. Multiple studies show that pauses are inversely related to survival: the more pauses you have the lower your survival.

54. Compression shold be fast 100-110 per minute Compressions should be hard Compressions should be uninterrupted The recommendation is Option A: endotracheal intubation, get ready with stylet in tube, tube in mouth, larangoscope in mouth and intubate during change over from one person to the next at the 2 minute mark. If unsuccessful after first attempt, place a supraglottic airway. Option B: Use only a supraglottic airway.

55. Decompressions or recoil During decompression you recoil off the chest and this represents diastole in the normal cardiac cycle. The heart doesn’t get any blood when you compress the chest, only when you release. So you need to release completely because you need to allow full recoil to get the heart as much blood as possible. Recoil is directly related to survival. The better your do it, the higher the survival. If you linger with just hand pressure (5 pounds) survival goes down 0ver 30%! The goal is fingertips only on the chest during recoil.

56. The heart gets it’s blood during recoil or decompression. Your Palms must be off the chest with only finger touching. If your hands rest on the chest it’s five pounds of pressure and you decrease heart perfusion by 30%. This decreases the patients chance of survival. It also increases pressure on the veins draining the brain, so blood can’t drain and then blood can’t get into brain. This means more brain damage and more deaths.

57. Limit Pauses to bare minimum! When you stop it falls back to zero and it takes several compressions to build it back up. Every 3 second pause means 16 seconds to recover the blood flow, which really means a 19 second pause. Multiple studies show that pauses are inversely related to survival. In other words the more pauses you have the lower your survival.

58. American Heart Association research shows longer pauses mean less survival. Statistically if you measure pauses preceding a shock or following a shock it has this effect on survival 10 second pause 80% survival 15 second pause 40% chance survival 20 second pause 1% chance of survival

59. We have discussed the first two component compression and decompression. Now let's discuss ventilation.

60. Ventilation- It is important to remember that we breath by expanding our chest and lowering our diaphragm to create negative pressure within the chest and then we literally suck air into our lungs because of this negative pressure. We create this negative pressure not just inside the lungs, but the whole chest. This is important because we use this same negative pressure to fill the lungs with air AND the heart with blood. Positive pressure ventilation like bagging the patient reduces the negative pressure inside the chest and it reduces the normal filling of our heart.

61. Ventilation So when we bag a patient, every breath decreases cardiac filling and therefore decreases cardiac output or blood flow to the brain and also to the heart. In a cardiac arrest the cardiac output is already very low, so ventilation can have a large impact. The AHA recommends you give 6-10 breaths a minute. It is also recommended that there be no pause in CPR for breaths, as there is evidence that this improves survival.

62. Ventilation The procedure for intubation is : Option A: endotracheal intubation, get ready with stylet in tube, tube in mouth, larangoscope in mouth and intubate during change over from one person to the next at the 2 minute mark. If unsuccessful after first attempt, place a supraglottic airway. Best is no pause or 3 second pause. Option B: Use only a supraglottic airway..

63. To Review: Ventilation reduces the negative pressure in the chest and reduces the amount of blood filling the heart. This decreases the amount of blood you are able to pump to the heart and brain during chest compressions. The American Heart recommends the minimum number 6-10 / minute. Avoid hyperventilation because it kills patients. Ensure proper volume and a quick small breath Interpose breaths with continuous compressions no stop for breath Intubate during changeover in compressors, no pause or 3 second pause only. One attempt, then supraglottic airway.

64. 64 Next the AHA guideline on movement. It is very important to remember that following the AHA guidelines doesn't just mean following the algorithms. In order to get the maximum benefit or maximum number of lives saved we must follow the guidelines as well.

65. Movement: The American Heart Association recommends no movement in the pre-hospital setting until a pulse is recovered. Unless the patient is in the water or another situation where it is clearly unsafe to defibrillate or do CPR. The reason is Multiple studies show that CPR during movement is insufficiently deep, not fast enough and there isn't enough recoil to provide enough blood flow to the heart and brain for success. Basically it causes several minutes of delay in the resuscitation. Because your not doing effective CPR. (the Medics in Seattle told me "...your not doing real CPR, your doing phony CPR, if you think your doing real CPR your fooling yourself, but it don't fool the patient." (Ouch!) Then they said "...it's the truth, so get over it, focus on the patient and do what's best for them, now that you know better."

66. 66 The AHA recommends that prehospital care providers not move the patient because that CPR during movement is insufficiently deep, not fast enough and there isn't enough recoil to provide enough blood flow to the heart and brain for success resuscitation.

67. 67 You have ten minutes to save a patients life. Statistically it takes at least four minutes for a first responder to arrive. If you take only 2-3 minutes to move them. You have burned through 6-7 of their 10 minutes and they are now out of the electrical phase and their survival has dropped by almost 30% just by moving them. ATP level is 30 less then you got there & the patients chance of survival has been greatly reduced. When you only have ten minutes a 2-3 minute delay is to long.

68. Movement: The American Heart Association recommends no movement in the pre-hospital setting until a pulse is recovered. We just reviewed the first reason is because CPR during movement is very poor. The second reason is patients who are coded in place have a higher survival rate and better neurologic outcomes. Seattle does move their patients, they code in place.

69. 69 The AHA says don't move patients because patient's who are coded in place, have a higher survival rate and better neurologic recovery.

70. Movement: The American Heart Association recommends no movement in the pre-hospital setting until a pulse is recovered. The first reason is because CPR during movement is poor. The second reason is patients who are coded in place have a significantly higher survival rate and better neurologic outcomes. The third reason is that BLS and ACLS in the field by experienced pre-hospital providers has been studied and compared to BLS and ACLS provided in a hospital emergency room. And pre-hospital care providers do as good a job or better then their hospital counterparts.

71. 71 American Heart Association states all studies show that pre-hospital care providers do as good a job or better then their hospital counterparts with cardiac arrest resuscitation.

72. Movement The American Heart Association recommends no movement in the pre-hospital setting until a pulse is recovered. The first reason is because CPR during movement is poor. The second reason is patients who are coded in place have a significantly higher survival rate and better neurologic outcomes. The third reason is that studies of BLS and ACLS in the field by experienced pre-hospital providers has been compared to BLS and ACLS provided in a hospital emergency room. The pre-hospital care providers do as good a job or better then their hospital counterparts. The fourth reason is that an ER has nothing to offer a pulse- less cardiac arrest patient that an ALS EMS unit can’t offer.

73. 73 The AHA says an ER has nothing to offer a pulseless cardiac arrest patient that can’t be provided by an ALS unit at the scene.The AHA says an ER has nothing to offer a pulseless cardiac arrest patient that can’t be provided by an ALS unit at the scene.

74. Movement So when you look at the four reasons for not moving a patient: 1.CPR during movement so poor it's like not doing CPR. 2. Patients who are coded in place have a significantly higher survival rate and better neurologic outcomes. 3. Pre-hospital care providers do as good a job or better performing BLS & ACLS then their hospital counterparts. 4. An ER has nothing to offer a pulseless cardiac arrest patient that an ALS EMS unit can’t offer. The AHA recommendation is that patients should be resuscitated in place, as there are no advantages to moving cardiac arrest patients before they get a pulse back and only disadvantages resulting in lowered survival.

75. 75 The AHA recommendation is that patients should be resuscitated in place, as there are no advantages to moving cardiac arrest patients before they get a pulse back and only disadvantages resulting in lowered survival.

76. Movement: Do you know that EMS providers are more likely to be injured or killed while traveling lights and sirens? That’s probably not a newsflash. But did you know that that the majority of deaths and injuries occur while transporting cardiac arrest patients? The reason suggested by OSHA is that EMS providers are statistically more likely to not be wearing safety belts during those types of transports because they are doing CPR.

77. Movement: So according to the AHA and OSHA’s statistics moving a cardiac arrest patient who hasn’t regained a pulse has clearly been shown to reduce the patient’s chance of survival. Such patient movement also increases your risking of an injury or death. While also reducing the patient's chance of survival.