The Prehospital & The Prehospital & Transport Medicine Transport Medicine Research Program Research Program Sunnybrook & Women’s College Health Sciences Centre
The Prehospital & The Prehospital & Transport Medicine Transport Medicine Research ProgramResearch Program
Sunnybrook & Women’s College Health Sciences Centre
Toronto Regional Toronto Regional RESCUeNETRESCUeNET
TORONTO Regional RESuscitation TORONTO Regional RESuscitation RESearch RESearch oUt of hospital oUt of hospital NETworkNETwork
Toronto Regional Toronto Regional RESCUeNET SitesRESCUeNET Sites
DurhamDurham HamiltonHamilton MuskokaMuskoka Ontario Air Ontario Air
Ambulance Ambulance ProgramProgram
PeelPeel SimcoeSimcoe TorontoToronto YorkYork
The ROC Structure:The ROC Structure:The 30,000 Foot OverviewThe 30,000 Foot Overview
National Institute of Health(NIH)
Resusitation Outcomes Consortium
(ROC)
University of Washington(Data Coordinating Centre)
Canadian Institute of Health Research
(CIHR)
Departments of Defense(Canada & US)
10 Sites(2 Canada & 8 US)
Toronto RegionalRESCUeNET
· 8 EMS Services· 32 Fire Services· 28 Dispatch Centres· 5 Base Hospitals· 53 Receiving Hospitals
RegistryRegistry Epidemiological Databank (Epidemiological Databank ( registry) of:registry) of:
– Out-of-Hospital Cardiac ArrestsOut-of-Hospital Cardiac Arrests– Major traumaMajor trauma
Population based (includes all cases)Population based (includes all cases)
In-hospital outcomesIn-hospital outcomes
Regional specific information to the Service / Base HospitalRegional specific information to the Service / Base Hospital– Web-based and password protectedWeb-based and password protected
Form the basis of a Canadian Registry of Out-of-Hospital Form the basis of a Canadian Registry of Out-of-Hospital ResuscitationResuscitation
CIHI – linkage with other data sets (trauma, cardiac care, stroke, CIHI – linkage with other data sets (trauma, cardiac care, stroke, oncology)oncology)
Compelling EvidenceCompelling Evidence
NegativNegative e
ImpactImpact
NeutraNeutraIImpacIImpac
tt
PositivPositive e
ImpactImpact
More Compelling More Compelling EvidenceEvidence
CobbCobb – observational - 1999 (3 years-639 pts vs 2 years- – observational - 1999 (3 years-639 pts vs 2 years-478 pts)478 pts)– 90 seconds CPR prior to shock 90 seconds CPR prior to shock – survival to hosp discharge (30% vs 24%)survival to hosp discharge (30% vs 24%)
WikWik – randomized - 2003 (200 pts) – randomized - 2003 (200 pts)– 3 minutes of CPR3 minutes of CPR– survival to hosp discharge (22% vs 15%)survival to hosp discharge (22% vs 15%)
AbellaAbella – prospective observational study – 2005 (67 pts) – prospective observational study – 2005 (67 pts)– Ventilations rates of 20/min (61%) (AHA guidelines are 10 to Ventilations rates of 20/min (61%) (AHA guidelines are 10 to
12/min)12/min)
WikWik – prospective observational study – 2005 (176 pts) – prospective observational study – 2005 (176 pts)– Rate of compression 64/min (AHA guidelines are 100/min) Rate of compression 64/min (AHA guidelines are 100/min) – Depth of compression 34 mm (AHA guidelines are 38 to 52 mm) Depth of compression 34 mm (AHA guidelines are 38 to 52 mm) – Hands off time 48% (38% when exclude ECG & shock analysis)Hands off time 48% (38% when exclude ECG & shock analysis)
Three-Phases of VFThree-Phases of VF
0 2 4 6 8 10 12 14 16 18 20
Arrest Time (min)
Circulatory
Phase
Elec trical
Phase
Metabolic
Phase
Shock CPR ?
Analyze Later versus Analyze Later versus Analyze EarlyAnalyze Early
300 compressions
Apply AED& Turn On
Apply ITD30-60 sec
Compressor Other Provider(s)
Analyze/shock
ACLS
3 min
50 +compressions
Apply AED& Turn On
Apply ITD30-60 sec
Compressor Other Provider(s)
Analyze/shock
ACLS
WHO? WHO?
Inclusion Criteria:Inclusion Criteria: Age Age >>18yrs18yrs
Non-traumatic cardiac arrestNon-traumatic cardiac arrest
Receive defibrillation &/or CPR by EMSReceive defibrillation &/or CPR by EMS
AdvantagesAdvantages
250 ml ~ 3 litres of Ringer’s 250 ml ~ 3 litres of Ringer’s lactatelactate
↓↓ early systemic inflammatory early systemic inflammatory responseresponse
↓↓ incidence of sepsisincidence of sepsis
GoalGoal
↑↑SurvivalSurvival
↑ ↑ Cognitive PerformanceCognitive Performance
↓↓ Multi Organ Dysfunction Multi Organ Dysfunction (MOD)(MOD)
Who?Who?
Hypovolemic Cohort Inclusion Criteria:Hypovolemic Cohort Inclusion Criteria: Blunt or Penetrating TraumaBlunt or Penetrating Trauma
Prehospital SBP Prehospital SBP – < 70 or < 70 or – SBP 70 - 90 & HR > 108/minSBP 70 - 90 & HR > 108/min
Age Age >>15yrs or >50kg15yrs or >50kg
Who?Who?
TBI Cohort Inclusion Criteria:TBI Cohort Inclusion Criteria: Blunt traumaBlunt trauma
Prehospital GCS Prehospital GCS < < 8 and 8 and prehospital SBP >90 mmHgprehospital SBP >90 mmHg
Age Age >>15yrs or >50kg15yrs or >50kg
What is Being Asked of What is Being Asked of the You?the You?
Registry: Identify Registry patients Registry: Identify Registry patients
CPR: Pads on patient; 50 or 300 compressions / CPR: Pads on patient; 50 or 300 compressions / analyzeanalyze
ITV: Attach valve to mask or ET tubeITV: Attach valve to mask or ET tube
Hypertonic Saline: Piggy back 250 ml bag / bolusHypertonic Saline: Piggy back 250 ml bag / bolus
Common to all Studies: Data Collection Sheet Common to all Studies: Data Collection Sheet