CBT Instructors Workshop

1. CBT Instructors Workshop

2. 1 2 3 4 Today’s Topics State of King County EMS CPR: Then and Now New CPR Guidelines ROC Study

3. 1 State of King County EMS2006 Mickey Eisenberg, MD, PhD Medical Program Director

4. 1 What We Have Accomplished?

5. 1 Time of Response

6. 1

7. 1 Age Distribution

8. 1 Responses by Type

9. 1 Location

10. 1 Cardiac Arrest Total number of cardiac arrests for all causes with resuscitation attempted:

11. 1 Survival

12. 1 Past Year • Infectious Disease Plan • ROC infrastructure established • CPR/Defibrillation protocol changed • EMT naloxone

13. 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%.

14. 1 Past Year • Infectious Disease Plan • ROC infrastructure established • CPR/Defibrillation protocol continuation • EMT naloxone • SPHERE pilot

15. 1 JEMS: June 2006

16. 1 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

17. 1 SPHERE Pilot

18. 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.

19. 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.”

20. 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.

21. 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

22. 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

23. 1 High Blood Pressure Alert Eligible patients: • Systolic BP > 160 or • Diastolic BP > 100 Not eligible: • Paramedic transported patients • Nursing home patients Documentation is mandatory.

24. 1 High Blood Sugar Alert Eligible patients: • Diabetic: BS > 300 • Non-diabetic: BS >175 Not eligible: • Paramedic transported patients • Nursing home patients Documentation is mandatory.

25. 1 Low Blood Sugar After-Care Instructions Eligible patients: • Patients on insulin • Low blood sugar • Respond fully to therapy Documentation is mandatory.

26. 1 2007 EMT Evaluations Underway • Study of glucagon for hypoglycemia • Study of left-at-scene patients following treatment for hypoglycemia

27. 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.

28. My Thanks It is an honor to work with you all. Dr. Mickey EisenbergMedical Director

29. And Finally • Questions • Suggestions • Comments • Clarifications • Opinions • Orations

30. 2 CPR: Then and Now Mike Helbock, M.I.C.P., NREMT-P Manager – EMS Training and Education Seattle/King County

31. It’s all about history, learning and and moving forward…

32. 2 Seattle’s First Medic Unit “Moby Pig”

33. 2 So…what’s on the ‘New to Do” list • New thoughts…. CPR compression/numbers • “Quality” of CPR (DVD-R) • NEW airway obstruction techniques • Resuscitation Outcome Consortium

34. 2 New thoughts on the numbers *One minute of CPR between shocks may not be enough…

35. 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!

36. 2 A Little Background Each of the links in the chain of survival are important for resuscitation. 9-1-1 Early CPR Early Defib Timely ALS

37. 2 Background, continued Though the emphasis has been placed on early and frequent defibrillation. 9-1-1 Early CPR Early Defib Timely ALS

38. 2 Background, continued This emphasis makes sense because the chances of survival from ventricular fibrillation decrease 5% for every minute without defibrillation. Survival 5 10 15 20 Time (in minutes) Valenzuela et al, Circulation 1997

39. 2 10 8 6 Minutes 4 2 0 1977-81 1982-85 1986-89 1990-93 1994-97 1998-2001 Background, continued With the introduction of AEDs for use by the EMTs, response time to defibrillation decreased in King County. Rea TD et al. Circulation

40. 2 Background, continued We hoped the reduction in time to defibrillation would produce better survival results. 50 40 30 Survival 20 10 0 1977-81 1982-85 1986-89 1990-93 1994-97 1998-2001

41. 2 Background, continued What actually happened: 50 40 30 Survival 20 10 0 1977-81 1982-85 1994-97 1998-2001 1986-89 1990-93

42. 2 Background, continued So we reviewed the AHA protocol which was: • Determine VF. • Stacked shocks. • Pulse check after each shock. • 1 minute of CPR and re-analyze. AND………

43. 2 Background, continued We looked more closely at the relationship between CPR and defibrillation from a physiological standpoint. 9-1-1 Early CPR Early Defib Timely ALS

44. 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.

45. 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.

46. 2 In With the New Eliminated stacked shocks. 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. The goal was to increase CPR especially during the period immediately following the shock.

47. 2 What happened since the change? Time to CPR after the shock decreased from 30 seconds to 6 seconds. Duration of CPR increased from 50 seconds to 95 seconds. Survival to hospital discharge went from 33% to 46%.

48. 2 Summary *More “hands on” *Less shocks *More focus on “Quality CPR" *New methods of resuscitation - cooling - ITD - mechanical devices

49. Which brings us to the question: CAN WE DO EVEN BETTER?

50. 3 New CPR Guidelines